CIHM 

ICMH 

Microfiche 

Collection  de 

Series 

microfiches 

(Monographs) 

(monographies) 

Canadian  Insfitu***  for  Historical  MicrorBproductions  /  Instlt-l  canadien  de  microroproductions  historiques 


I 


Technical  and  Bibliographic  Notes  /  Notes  techniques  et  bibliographiques 


.  iG  Ino'it'Jte  has  attempted  to  obtain  the  best  original 
rnpx<  available  for  filming.  Features  of  this  copy  which 
.Ti?y  C3  bibiioqraphically  unique,  which  may  alter  any  of 
the  i  r.ages  n  the  reproduction,  or  which  may 
'^.'oniiicantiy  change  the  usual  method  of  filming  are 
che  -ix-ri  beiow. 


□ 


n 


Coloured  covers  / 
Couverture  de  couleur 


I      I    Covers  damaged  / 


Couverture  endommagee 


□    Covers  restored  and/or  laminated  / 
Couverture  restauree  el'ou  pelliculee 

i    Cover  title  missing  /  Le  titre  de  couverture  manque 

I I    Coloured  maps  /  Cartes  geographiques  en  couleur 

□    Coloured  ink  (i.e.  other  than  blue  or  black)  / 
Encre  de  couleur  (i.e.  autre  que  bleiie  ou  noire) 

I       1    Coloured  plates  and/or  illustrations  / 
' 1    Planches  el'ou  illustrations  en  couleur 


□    Bound  with  other  material  / 
Relie  avec  d'autres  documents 


D 


Only  edition  available , 
Seule  edition  disponible 

Tight  binding  may  cause  shadows  or  distortion  along 
interior  margin  /  La  rei.ure  serree  peut  causer  ce 
I'ombre  ou  de  la  distorsion  le  long  de  la  marce 
interieure. 

Blank  leaves  added  dur  ng  restorations  may  appear 
within  the  text.  Whenev(9r  possible,  these  have  been 
omitted  from  filming  /  II  se  peut  que  certaines  pages 
blanches  ajoutees  lors  d'une  restauration 
apparaissent  dans  le  texte,  mais.  lorsque  cela  etait 
possible,  ces  pages  n'cnt  pas  ete  filmees. 

Additional  comments  / 
Commenlaires  supplementaires; 


L'Institut  a  microfilme  le  meilleur  exemp'.:;  re  qu'il  lui  a 
ete  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire  qui  sont  peuf-etre  uniques  du  point  de  vue  bibli- 
ographique,  qui  peuvent  modifier  une  image  reproduite, 
ou  qui  peuvent  exiger  une  modification  dans  la  metho- 
de  normale  de  filmage  sont  indiques  ci-dessous. 

Coloured  pages  /  Pages  de  couleur 

I I    Pages  damaged/ Pages  endommagees 


□ 
□ 

□ 
□ 


L 


n 


Pages  restored  and/or  laminated  / 
Pages  restaurees  et/ou  pelliculees 

Pages  discoloured,  stained  or  foxed  / 
Pages  decolorees,  tachetees  ou  piquees 

Pages  detached  /  Pages  detachees 

Showthrough  /  Transparence 

Quality  of  print  varies  / 
Qualite  inegale  de  I'impression 

Includes  supplementary  material  / 
Comprend  du  n.iteriel  supplementaire 

Pages  wholly  or  partially  obscured  by  or.ata  slips, 
tissues,  etc.,  have  been  refilmed  to  ensuie  the  best 
possible  image  /  Les  pages  totalement  ou 
partiellement  obscurcies  par  un  feuillet  d'errata,  une 
pelure,  etc.,  ont  ete  filmees  a  nouveau  de  fa^on  a 
obtenir  la  meilleure  image  possible. 

Opposing  pages  with  v,Kying  colouration  or 
discolourations  are  filmed  twice  to  ensure  the  best 
possible  image  /  Les  pages  s'opposant  ayant  des 
colorations  variables  ou  des  decolorations  sont 
filmees  deux  fois  afin  d'obtenir  la  m.eilleure  image 
possible. 


This  Item  Is  tilrripd  at  the  reduction  ratio  checked  below  / 

Ce  document  est  filme  au  taux  de  reduction  ind.que  ci-dpssous. 


lOx 

14x 

18x 

22x 

26x 

30x 

1 

1 

1 

1 

12x 


16x 


20x 


24x 


28x 


32x 


The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

J.J.    Talman  Regional    Collection, 
D.B.   Weldon   Library, 
University  of  Western  Ontario 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  soecificationa. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  —^-  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 


L'exemplaire  film*  fut  reproduit  grace  d  la 
g^n^rosit^  ae: 

J.J.  Talman  Regional  Collection, 
D.B.  Weldon  Library, 
University  of  Western  Ontario 

Les  images  suivantes  ont  iti  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
de  la  nertet*  de  l'exemplaire  film*,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 

Let  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprim^e  sent  filmis  en  commencant 
par  la  premier  plat  et  en  terminant  soit  par  la 
derniAre  page  qui  compone  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  selon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  film*s  en  commenpant  par  la 
premiere  page  qui  compone  L,ne  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  derniAre  page  qui  comporte  une  telle 
empreinte. 

Un  dee  symboles  suivants  apparaTtra  sur  la 
derniire  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  —^  signifie  "A  SUIVRE",  le 
symbole  V  signifie   "FIN". 


Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  cartes,  planches,  tableaux,  etc.,  peuvent  etre 
film*s  i  des  taux  de  reduction  diff^rents. 
Lorsque  le  document  est  irop  grand  pour  etre 
reproduit  en  un  seul  cliche,  il  est  film*  ^  partir 
de  Tangle  supirieur  gauche,  do  gauche  d  droite. 
et  de  haut  en  bas.  en  prenant  le  nombre 
d'images  necessaire.  Les  diagrammes  suivants 
illustrent  la  m^thode. 


1 

2 

3 

4 

5 

6 

MICROCOPY    RESOLUTION    TEST    CHART 

-NSl  ond  ISO  TEST  CHART  No    2 


1.0 


I.I 


2.0 
1.8 


1-25    III  1.4     i  1.6 


.=      -IF^PLIED  \MA3E     Inc 


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'western  uNivtRsmr^  $'y 

MtDlCW.  SCHOOL      " 


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'BF=»A' 


THE  PHTHALEIN  TEST 

An  Fxperim.nial  and  Clinical  Study  of  Ph.nolsulphone- 

phthalein  in  Relation  to  Renal  Function  in 

Health  and  Disease 


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i;,,,ri„lr,l  fmm    ihr   Mchiies  of   Internal    M<.Uri<,r 
M.inh.   V.ni.   Vol.  •!.  ;.)).   -''^i  •!•!"- 


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ClUCAOO 

\MI  lir.AN     Mll'l.Al.    ASSIIII.VIIUS 
HK    in   Sl.IU;n    AM'    TlMIin-l-lVI     PKARn.illN    AVKXIE 

I'.llJ 


...Oi\.^-.r:  .  .     .04. J 
.  o;  cris.1  Voluiio 


TUK     I'llTriAI.KIN"     TKsr 

A\   i;xpi;i(iMi;.s"r\i.   and  iumcm,  .--ri-DV   (if   i'iii:\oi.sn.i'iio\i:i'inii  \- 

LiJi.N  i\  i;i:i,\Tiii.v  TO  i;i:\A[,  irxcTiox  i\  liicAi.ra 

AM)  i)isi:\si:  * 

1.,  (;.  i;n\\Mi;ii:.  md,  an,,  ,r    i.  (;i;i;  ahii  l^•.  m  d. 

l:\il  IMcil.'L 

I'ii('iinl>iil],linm'i)lilli!ili'iii,  uliiili  Wiis  lli-t  ili^niliiil  liy  Kmi-on,"  is  ;l 
Kri-M  ivi\  c-rv?tallii:c  imudci-.  M.iiiru  hat  m,1uIiIi'  in  w.'it.r  and  a!r(ili(il  and 
'■'■adily  x.'nl.lr  in  tic  |nv.,.ii(c  ol'  a]!.:alic^  'I'ln-  dm;',  a^  dft-rinincd  l.y 
Alu'l  aihl  i;.)\\  niri'..-'  i-  unii-ln.rir,  iiiiii-irrilinil  lui-dlv.  and  '-  cMivtrd 
Ii!aftiia|!y  ('i!iirr!\-  |.\  tlic  kidnr\~  :iihI  \^illl  i'\t  rancd  inai  \-  raiiidit\-. 
apprarinL'  in  tli^  mini'  linniiaily  \\it!;in  ::  fru-  ininuti'-  of  injictinii.  In 
alkaliiU'  solution  it  ]nr-(  iit>  a  hfilliant  ifd  co'or  wliicli  is  idi-a'lv  fidaptml 
I'oi'  ([uantitativr  coloriin' trie  ''-timation. 

Tie  I  ink; 

In  onv  pailii-l  uorl<  onlv  llu'  linio  of  apiiiMraiKi'.  tlie  tinv-  of  nia\i- 
niiiin  inlr-n-ity  of  rM'ivtion.  ;uid  llio  tiinc  o!'  lto-s  elimination  wciv  con- 
^i<!fi'''d.  In  tJK'  roni-^'  of  the  \\.)rk-  it  lir.  aim-  cvidt.'nt  that  thi'  i-ohir 
propertit-;  uf  this  suli.-taiuv  nMhc  it  pi-niliarly  woll  adaptod  for  coloii- 
inetrie  nicthoils  of  I'.-limation.  ajid  for  tlii-  pnipose  tin-  I)uho-((|  coloii- 
niotfi-  wa-  cinphiMMl  and  lia^  iirovcd  of  the  Liiiatr-t  valiir. 

In  onlrr  to  ohiain  data  "f  ival  \a!iio  it  i-  c— cniial  to  anv  runctinnal 

ti-t  to  kn.iw.  n..t  oidv  t!:.'  tii )f  appia'an-c  of  thi'  dniu'  in  the  iirini'. 

Iiiit  cMU-tlv  wliat  pall  of  tlic  diaiL'.  a  kn.iwn  .•inioimt  of  whii-li  lia^  li-on 
adniinistiacd.  i>  niovoud  in  a  drtinitc  period  of  time. 

Twenty  niinuto-  to  half  an  liour  hefore  administei  ini:  tlie  test,  tlio 
patient  i-  L'iven  '.'OM  t,,  lod  ,■.,..  ,,f  unt.r  in  onhr  to  in^ive  free  urinarv 
^eer^■tio?l.  dtlierui-^e  de'av.'d  tine-  of  apjiraranee  mav  hi'  due  to  lark  of 
'■eeretion. 

I'ndei'  a-eptie  piecanlion-  a  rathoti-r  i-  inliodneed  into  I'le  Madder 
and  the  hhid  Iei-  (.imphtelv  (anptied.  N'otitiL'  tl"'  time.  1  e.e.  of  a  eai'e- 
fnll\-  ]'repai'ed  -ojutioir''  of  the  pheiiol-nlphoriephtlialein  eoidainiiiL'  0  m<x. 

•From  till'   l'li,niiKic.iI,:..ic';il   I.;!l„ii;il(.i  v  nf  Ih,.  .7,,lin~  llepkin-   I"iii\  ,i -il  \    nri  I 
tie'  foMiitn  I'iiri:ir\    aini   Mr.lieiil  (  liiiic-  c.f  t  lir  .!(,!. ii-  llupkin-  !ln-|.i|;il, 
I.    Ki'ie-sMi:    \in.  I  It, mm.  .Icmh'.   ls><t.  \\.  ■J'-n 
■-'.    \l>el  1111(1   Itcnvnlrr,.:   .I,.ur.   riiinii    ;iiel   i:\|..i    'riicinji.,   IIHVI.  i.  2:11. 

:\.     llii^    -ellltinii     i-;    (iM;inir(|    ii »     fell.nv-:     di;    ;.'ni,    of    pil(<noK\ll[llintlr|i|llli:llrin 

ntiil  (IS  I  !■  <■.  .if  il.Hil.Ir  lenriKil  -ii,liiiiii  liy,lre\icl  soliitieii  iirc  ililiilccl  vvitli  (I.T.'i  [icr 

c-i'iil,  -n.liuiii  chlMriil   ■.,iliili.,ii  ii|i  til   IIMI  ce.     'I'liis  ^'ives  tlie  iiinTin-^niliinn  nr  iicid 

■■■ill.  \'  I  IN  1 1  1-  o  a  in  ,.il..r  ;o  .1   wliich  i-  -liLililly  irritant  Ineiillv  «  IhMi  iiii.'rlrd.     It 

is  ncpes^^ary.  ttiercfnrr'.  t(i  nilil  0  1.")  re,  iiiure  c,f  tin'  twin'  rnineiil  livilrnxid.  a  ,|ii;iii- 

titv  ^IllVlcir'll  III  il,:lllL.'e  till'  iia.ir  111  :i  lii'lllltiflll  |!nl.liMII\  V'A .  'I'lli-  |  .1  I'p^l  Ol  1  ii  i|l 
i-   licill  ill  il:o:t 


to  the  c.c.   i<  aKiirat'ly  .■hliiiiTii,-ti-i'Ml   miIm  iilancoii>!y.   iliti:lliirM-ii';ii-lv  ni- 
iiitnivniMii^ly  liv  inc-iii-  (i(  all  iKrii lately  ;;rmliiatcil  fyrin_s:o.* 

■|'l"'  ii'i"«'  I-  iil!'i»r,|  1,,  ,!!aiii  into  a  t.'st-tiiI,M  in  uliirli  lia^  li.cii  |ihuril 
a  (Imp  of  •;:<  \<-r  .cut.  soiliimi  liyilnn.iii  >oliili,,n  and  tlic  time  ol"  tlic 
appraraiiii.  nl'  t|i,.  i;.-t  fainl  jmiki-li  liiiirc  is  iiotcl. 

In  [latitnls  «itiiout  miliary  (il.sfiiictioii  tlie  lalln  tt  r  i-  witlaliawn  at 
till'  tiiiir  r(  thi'  :i|.pi'aiaiir.'  ol'  (h,.  ,ln;^r  j,,  t],,,  ,in,,r.  and  the  patient  i- 
in-tiurt>(l  t"  VI, id  info  a  n(0]ilaeic  at  ll:r  end  ol'  one  lieiir  :.ih1  ii^to  a 
?eiond  mepta(!e  at  tlie  end  of  the  second  liotir. 

A  1(ii:l;1i  e-^tiniato  of  tlie  time  of  appearanrc  ean  lie  made  l,v  liaviiiL' 
llie  patient  void  urine  at  fieipu-nt  intervals  without  tlio  use  of  tlii' 
eatlieter.  In  prostate  ea-es  it  i~  wi^^.'  to  lia\e  the  ealle  ter  in  place  niiti! 
tlie  end  of  the  Ml,~ri\aiinn.  The  eatliet,  v  i.  (.,,:h,  d  at  the  time  of  the 
ap|ieaiaiiee  nf  il:,  diii.'  in  the  urine  ami  the  eori;  i-  removed  iit  the  end 
"I'  the  fii-t  hniii-  and  ai  ihe  en.l  of  the  seeoiid  hour,  the  Madd-r  h-iiiL' 
thoroughly  drained  eaeh  time.  On  many  of  the  patients  nf  tliis  Ivpe  on 
whom  our  oh-i  rvalion>  liav,.  h.  en  made,  a  retention  eatlieter  has  heen  in 
'I-''  •■'"  l':ii'l  of  the  routine  tieatnient  on  an-oiint  of  the  r- -idual  iiriiie. 
W  li.ii  a  tat  Inter  i~  t^  he  rniployed  it  is  well  ]irev!oi'-!y  to  have  the  patieii; 
under  tl;e  iiiiliiriHc  nf  he\n mctliv lennMi  1  n. 

Kaeli  sampV  (d'  mine  i-:  mea>mvd  and  the  spe-ifie  ^ravitv  taken. 
Siiilicient  sodium  hydiHvi.l  {2',  per  cent.)  i-  added  to  make  t!ie  urine 
decidedly  alkaline  in  ort'er  to  elicit  the  nuixiimim  color.  The  lolor 
displayed  in  the  acid  urine  is  yellow  or  nranc-e.  and  thi-  iiiiiieili:ite|y 
uive-  plac,.  ti,  a  Inilliant  puiph-nd  (c.'ni-  \vheii  ihe  >(dution  hicomes 
alkaline.  Thi-  M.!iit:,.n  i-  n..w  plai.d  in  a  liter  ;iieasuriii,£r-fhi=k  and 
di-lilled  water  added  to  make  aeeiiintely  1  liter.  The  sidution  i^  then 
thoroiiLdilv  mixed  and  a  sirall  filtered  portion  tikcii  in  (nmpare  with  tht 
.standard,  which   is  ii<ed   fm-  all  of  the-c  e-tiiiritions. 

In  our  earlier  work  the  amount  of  diuj;  exerettd  was  estimated  liv 
means  of  the  l!uhosef|  eol,,rim.-t.r.  (he  t.ihnie  of  which  has  hcen  d,><ci  ihed 
111  our  oriL'inal  piihlication.-'- 

IJeceiitlv  the  .\iitcniieth-K(inie;sherijer  colorimeter''  has  been  modified 
I'V  'i~  ■'■'id  utilized  fnr  the  (piaiititative  estimation  of  phthalein.  .\ 
standard  alkaline  soliitinn.  tl  in^.  of  phtliah  in  to  the  liter,  is  phned  in  tlie 
Wcdjre-shap.'d  cup.  The  urine,  eolleited  as  for  the  ether  method,  is 
diluted  tn  a  liter  and  a  -mall  filtered  portion  poured  into  the  reetan^iular 
Pup.  The  wcdu'e-hap.d  rw^t  is  now  manipulated  hv  means  of  the  screw 
until  the  tw..  si.h's  of  color  fiehl  are  identienl  in  intensilv.  The  per- 
(cntaee  is  now  n  ad  directiv  hy  the  position  of  tin'  indieafnv  on  the  seale. 


4.   We  liiive  iHi.,i  tlie  Ii(T"iil  2  c  c.  syriiiL'e  wliicli  is  !,'rai|iiatc.|  in  !ifl!i^  of  ;i  ,.  p, 
.'c   'llii-   iii-liiiininl    is   iiKiiiiifiictincd   l.y    llclli..-,.   in    Fi,.ili,.r._r;   mir   nimlllifat  inn 

I'^iii  1 lil.iiiuM  fi.  Ill   llyn-en  uml  WVstpntt.  T^iltiimiro.  Afil. 

Mm,    l'l,;irni     anil    I'7\p>'!.   ■fliii-;i|i,,    I'lnn. 


3 

■|  hi-  iii-liuiiiint  is  \U'1I  :i(liihti(l  for  tin'  |iiii  pusi'.  i-  a|)|.r(i\iin;il..lv 
iici-iiiiilr.  iiiiil   i-  iiiiu'li  cluMi'tT  iliiiii  till'  l)iili():-i(|  ciiluriiiict.  r. 

Fiiirlv  lueiiriitc  estiliiiitiniis.  Iidwcvcr.  can  he  olitailioil  li';  me;ui-  of 
jiiiiilllalril  rvliiiilfis — t'(|lliil  i|iuiinili('s  ol'  till'  sl:ni(l:lld  -njuticiii  Mini  I.ic 
ililiitcil  iirino  lii'inu'  usrd  in  sopanitc  cyliiiil.T-  nml  tlir  d.  iisim'  sdlutidii 
lioing  diluted  iiiifil  tlic  cdlors  l)i'coiiie  idi'Titi.nl.  Tlip  niiioiint  of  dnii:  in 
till'    ?nlutiiiii    liriiiLT    known.    Ilio    ;iniount    in    llir    iirini'    rnn    lir    nniliiv 

Cillrld.-ltcd. 

\\\,i\\  the  cirllcii.d  iiiiiic  liiis  liirn  nuidi'  stion;:iv  iiik.din.  il  i-  ih ccs- 
siiv  t"  i-timntc  llif  plitkali'in  wiiliin  :i  few  li(ini>  a-  the  red  color  fado? 
L'nt'liiidly  nndci'  tlieso  conditions.  When  it  is  di>siral)l(.'  or  ncrc.'^sarv  to 
defer  the  csfinialioii  for  Mime  l)onr<  or  days,  it  is  better  to  make  the  urine 
distinctly  a<-id.  iinih'i-  whidi  condilion  the  |iliiliali'iii  ii'min-  iini  lian-cd. 
It  -hoii'd  of  coiusc  he  made  alk.'dino  aL'ain  when  the  e^liination  is  made. 

'I'lie  nielhnil  heretofore  utilized  in  connection  with  other  test=.  of 
di'lcniiinin;.'  the  time  necessary  for  to'.-d  c'iniin.ilion.  is  cironeous  lor  the 
folhiwim;-  iva-dii:  Whereas  in  ihc  ca-e  of  |ihth.'il.'iii.  a  normal  kidm  \ 
CM-i-elcs  till'  ;.'i'eater  pait  of  the  d\e  injiclcd  within  two  houv<  of  the  tii-^' 
of  its  admitiistration.  and  then  only  a  Miiall  tnuc  I'.ir  the  n.\t  luo  hom-. 

the  modei-alely  disca-^ed  kidiU'v  sec  lelc^  -a  fair  ; iinl  w  ithin  the  (ii-i  \\\,, 

hours,  ^ay  .V)  per  cciil.  (if  that  e.\creled  hv  the  nnii,ial  kidm-v.  lint  the 
i-oneeiitiation  in  tin'  hlond  >till  hi'iii;:  hi.irh  it  cnntinin-  tn  cNcicte  a  fair 
amount  in  the  follouin;:  two  lioiirs.  mi  that  at  the  i  nd  ,,:'  fdin-  •leurs  little 
dilVerence  may  i\i.-|  in  the  total  wmk  aeenmpli-iied.  One  h  iir  and  at 
nil -t  t'lVo-hoiir  o]i-ervation<  are  therefore  reconiniended.  In  ca-es  in 
whieh  onlv  s'iuht  ehanees  in  function  e.\i.-t  this  can  he  most  aiciiratelv 
deinoiHtrahd  hv  nne-hour  eojlectinii  folhiuioL'  the  ii-e  of  an  intra- 
mu-eul.-ir  ( liimh,-ir )    injertieii. 

iiii:  ixri.i'i  \ii:  or  tin;  i;.'ii.i:  m-  M'sm;;']  mv  ,iv  -pm;  uy'ri-: 
III"  i:\ri;ri'io\ 
Il  mii-l  he  adniitt.d  liiai  a  factor  otiiei-  than  ivria!  excn-tion.  vi/.. 
alisor|iti'in.  enter-  in  i  on>iderai  imi  in  luniicction  willi  the  ti-t  when  the 
phtliah'in  i-  adiiiini-lerd  -ii!  .  iitatie,ai-!\-  ><v  intraiini-eiilarlv.  ( Ihviniislv. 
a  enii-ideiMhle  eMur  i-  inlrniiiiied  I'ioiM  the  standpoint  of  ali-orption  in 
the  li-c  III'  the  -liheiit.llii  nil-  iiictliod.  \\i;en  factors,  -iieh  a-  edema,  which 
may  inodif\  the  rate  of  ah-nrpiini!.  ,  \i-t.  On  tlii-  account  the  excretion 
in  health  fiilli.\>ine  diU'eienl  nicthmU  of  adiiiini'^tiat  ion  ha-  heen  studied 
in  some  d'  tail. 


IN  ri;  wii  ,-(  n  m;    wo    ■-it,,  it  \\  iiic-    \iisim;|'|iii\    ,ii- 
si'i  I'liiix  ri'M  rii  \T.i:i\- 
Mellzcr  and  .\uer"  were  the  first  to  demon-trate  that  ahsorption  from 
tlip  intramuscular  tissue  is  much  more  rapid  than  that  frnni  the  -uhcuta- 


ti.  Slcltzcr  iind   .Viicr:   .lour.  i;\|ier.  Mni,.    lnn.'i,  \ii.  .i!i 


riciiii-  tissiirs.  Tliiv  uctlid  Willi  r|iiiic|.ln  ill.  luiniv,  lliio'r-iin  and 
inorjiiiiii.  ;;nil  (h  niui:-l  lalnl  Ij,  mhuI  doulit  tli.it  tlll■^('  -nlL-laiici'-:  loiind 
tlicir  way  iiitu  ti;i'  Liiuia!  i  irciihition  iuik  li  iiioii'  ia)iidlv  win  n  tlic 
iliji'ilinii-;  arc  made  inln  tiii'  inli-i  hv-.  I'alla'  Ma>  iiliaidr  In  d.In  I  aiiv 
ii,-r  id' l)l(i(iil-jiii-s-mc  lolli-uin^'  tli.'  int  raiiiii-iidai-  iiiirilidii  nf  i.>|.inr|ilirin 
and  (oiirludiMl  lliat  tin'  I't-idl-  dlilainrd  liy  Mclt,:ci-  and  Aiht"  wcw  in 
i''alil\  diir  In  iiili'aMiMn-  inj.Miinn-.  Wallace.''  vwnkini'  with  i>|iini'plii'in, 
iildainiM]  r.-u!t-  iiK'iiliial  with  ll'i's^'  of  .Mi^it/rr  and  Ancr.  livt  al-n  f(df 
lliat  till'  ri-iill-  Wcl"  dcp'ndilil  iMi  liaiilr^  nl'  thr  \,d;i.  ami  wriT  in 
rrality  iiilravrninis  iiijccti  mis.  d(i-r|ili  and  Mrh/rr.*'  in  tlirir  uoi'k  in 
rdatinn  lo  pliy-ncti^r,,,;;]  j„  |,i,j.;i,nj,,^r  \,y  maLrnr-ia  -ait-,  airain  diMiuiii- 
.^-ti'alcd  inl  laniii.-cid.ai-  ali-ni'jition  (.i  1„.  i'.h'  >ii|i('ri'n-  tn  >ulicntanoo\is. 
Au(>r  and  Mi'Mzi-r.'"  Iiy  nictlmd-  n-.  il  with  -|ii'idllc  inti-ntinii  "T  dctiH-tinir 
wlicthcr  the  r.aj'idity  (d'  inlraniiiMMdai-  ah-'ii|iti(iii  wa-  ilfpci'drnt  on  the 
trarinLf  id'  vein-  diiiinf  ilir  in jiTiini;-.  n;-  t'l  tin'  diit'ct  in.-rr1ir,n  of  tiie 
lioedli'  into  n  inu-i  |r  \rin.  |iin\(d  snti^lai  tnii'y  that  >n:di  .■iccldi'iitr:  wore 
not  n•>|)on^i!ll(■  fnr  (hr  lapidilv  nf  ali:-or]ition.  hut  th.at  lapid  ahsorption 
ocni'.-  throULih  ihr  wall-  of  ih..  l.lond-vc-Md-  of  thr  inu-tdc-.  l-i  the  >anio 
coinniiiniralinii  thr\  al.-n  a^-crtt'd  that  ah-orptimi  from  tin"  ininhar  i- 
mtirli  -iip(  :hn-  to  tlial    rmni  the  irhitciij  niiisflc-;. 

i'hrtiol-ulphnniphlh.alcin.  hv  viitth'  of  thr  pfnpi'ilit-  'Ahi'irhv  it  i- 
fapidl\-  -md  ipi.antitat  i\(dv  o\(  |-fiod  hv  thr  kidiii'V.  fiiini-hrd  an  oxrrlleiit 
init'i"d  nf  -liiilyiii','  thi-  pi'oh'rni.  .\n  inxi-t i'.'ation  into  tlic  conipar.ativo 
(|uaniitativ('  cMivtimi  nf  phi'tiol-nlphoiirphthalrin  follinvin:."-  tla-c  (wo 
inrthods  (d'  ndndin-lialioti   wa-  (  on-r(pirnt  I  v  iindcftakon. 

'I'hp  lii'-t  I'Npciiini'iit-  \\(M('  caifiid  on(  mi  hitrhr-.  'I'hi>  timo  of 
appraraiup  of  the  clfULT  in  'hi'  iiriin'  folhn\iii|_r  snhi-iitnnron-  adniini-tra- 
lion  <>{  1  cc.  of  jildlinlcin  -uliiti  .n  (i!  iws.)  and  tho  (pianlita(i\.'  output 
of  plithalrin  for  prri.uh;  nf  varviiii:-  hnLith-  \yvr  didcniiinrd.  'i'lie  Innihnr 
nni-rli'-  nf  th'^-c  ih"j-.  wiTo  t!nn  i  xpo-c.l  h\-  a  -trail  ii'i-inn.  diicid 
intianiii-onhif  inj'rlinii  niadr.  and  tlm  tiiiir  nf  appraraiiic  nf  tho  diaii;-  in 
the  minn  and  ihc  ipiaiitital  i\('  milpiit  fnr  i-nriT-pond  iinj  pic:  ind-  a^'iiin 
dctcfiniiird.  I''ina'i\'.  intfaM'tmiw  injortioti-:  woio  L:i\rii  and  similar 
oli-cr\atinn-  wrw  a::.-iin    niadi'. 

'i'hc  tiino  nf  apprai.iiiir  wa-  drlrrmiiii'd  a-  follnw-:  .\  catln'tcr  was 
passed  into  tin'  hl.aihh-r  and  thm  1  co.  of  -iilph.nneplithah'in  wa-  injcrtcd 
stihciitani'nii-l\-.  iiitiamn-'iihirlv  or  ini  ra\cnon.|y.  'I'lio  hhnldcr  w;is  then 
inji'rlid  at  .■10--,Tnnd  and  nm -niiniilt'  inh'fxaN  with  siral!  ipiantitic-  of 
warm  sleriK' hoi  ir  Miliit  ion  a'-d  llii-  wa-  inimrdiat' 1\"  draimd   into  thi-h- 


7.  ralla  :    Aoli.   il:il.   .!.■  I  i>'l  .   1!iiri;,   \|\i.    Hi:!, 

><.  UalllK.':    M.'l.    Ilrr,.    i:iii7.   Ksi.   STil. 

II.  .I..,,.|,li   .riiJ    Mrli/,.r:    .linir.    rimini,   ;ni.|    1-'^  |.('|-.    I  li.'i ;.  p..   lIHHi.  i,  :iti!l, 

111.  ,\ii.r   ami   .M,'ll/cr:    .Imir.   JAprr.    \Iiwl..   1:111.   \iii.   lijs. 


ooiitiiiiiiii!.'  a  fi-W  ilro|i>  o|  sniliinii  li\ilri)\iil.  'I'lic  ti  -t  iippuarance  of 
jilitliiiloiii  in  the  \vii.-liinjx.<  \va=  noted  .iiid  tli"  iuiKHiiit  of  dniL'  oxcrotcd 
for  the  vaning  periods  \va~  tl'.en  dt         i  led. 

The  results  obtained  from  these  .  vutions  appear  in  Table  1,  from 
a  f^tudy  of  whiili  it  will  he  seen  that  the  time  before  appean.nce  i? 
shortest  for  the  intravenous  and  that  the  druj:  appears  nmeh  more 
rapidiv  (3.5  to  T  min.i  followinji  an  intramuscular  than  fnllowinir  a 
subciitancon=  itijortion  (•').."■)  to  1*?  minutes).  The  aiuount  of  excretion 
is  depeiKleiit  on  liie  amnuiir  uf  absorption,  the  ki.ln.v  fuiution  not 
plilvinL'  a  io!e  inii-iinuli  a-  the  -an^  (Iolt-  were  ti-.  .1  th;'niii;liout  for  these 


I  I, art  I. — I  urve  i.i  I'xii  ^a.aai  in  a  ilu^'  lor  one  liour,  e.stimationri  licing  made 
at  len-niiniite  interval^.  TppiT  '.lack  line  rcpres.MUs  tlie  excretion  after  intra- 
venous, the  dotted  line  alter  intraiiia^cular  (lunibin  )  and  lon-r  black  line  after 
the  subciitaneiins  administratiun. 


♦        * 


experiments,  tlio  kidney  fiincti(ui  beiuj;  therefore  appr^-xiinately  the  same. 
It  appears  that  the  ahsoi-jjlion  for  one  hour  from  the  subcutaneous  tissues 
averages  from  .">  to  10  ]icr  cent,  less  than  that  from  the  intramM=fular. 
while  at  the  same  time  considerable  variation  (3T  to  02.8  per  cent.)  exists 
in  the  absorption  for  the  same  do,;;  (Dog  5.  Table  1).  The  absorption 
from  the  intram'iscular  tissue  for  one  liour  appears  to  display  less  varia- 
tion (58.8-OS  per  cent.'),  hut  the  absorption  is  not  .ibsohitely  complete,  as 


tlip  oxcix'tioti   I'lir  one  liuiii-   i^  siiiupwhat   !e>s   than   that    lolhuviiii:   intfa- 
vpnnii>  injections. 

'The  diffrreiic-o.  howt'vor.  in  ti.e  ahsoi'ption  I'loin  thf.-o  two  method? 
of  administration  is  mncli  more  strikiuij  when  oif  -lialf  hour  observations 
are  taken  i.mt  i\\i(e  as  iniieli  ahsni|ition  foHciwiii^'  intiaim;-' iiiai'  injec- 
tions i)s  (iiia|iare<i  witli  >tihenIaiieous  (Dogs  A  and  .".,  'lahle  li.  'I'his 
snjrgestcd  to  ns  tiie  idea  ol'  tlie  necessity  of  comparini:  the  curve  of 
excretion  in  order  to  obtain  the  real  difTerence  in  the  rate  of  absorption. 
Estimations  were  made  at  ten-niinute  intervals  followiiicr  injections  by 
all  tlirec  tnetbods  of  administration.  A  ("ni]iari-oii  of  tlie  excretion  in 
one  doir  (Xo.  .->,  Table  1)  is  indicated  in  Chart  1.  A  similar  comparison 
for  the  ('.\(retion  in  man  following:  intravenous,  lumbai-.  n-hiieal  and 
subciitaneoiis  administration  is  shown  in  Chart  'v. 


T.ABI.K    1. 


I    OMl>.Ml|S(l\    (IK    K\CUrTIIIN    111      I'|C1'IIMII\     IN     Doi,'-     lii!lil\\|M 

m:\ois.    In  MIWii  s(  1  I  .\k    i  I.i  miiaI!  i  .    anh    M  i:i  i  ia  ni  ni  -. 
Admin  I- MIA  uuv 


INII 


Doji  I 


Do- 


Do- 


1  imo  iif  .A|)|ieftrancp  .\iiioiint  l-l  '._■  Ilunr 

Snii-    Intra-     Tntm-  Siili      Intr:!-   Intr 

'•Ml.       iiin»,        veil.  cnl.        inii 

r>         1 1 . 


Ill 
11 

:i':.. 

1:; 

'l 

I 

r>i.. 

Ooi;  4 

I'l 

(  Pri>21l;Ult 

•' '  -• 
It 

a". 

■f. 

ti 

3'i 

1),.-  .". 

5 

Klj 

r. 

7 

r. 

s 

4 

-  t 

(•)    Not  rond. 

,)  '  ._• 

lll'l 

III 

111 


•Jir 
17.7 


lt.  :; 
■J.'  I 
1.'.  I 


51. 

46.S 


."W :) 


.\Tiii)iiiit  I  Umir 


ntVM 

Sill. 

Intra 

Intra 

vrn. 

.•III. 

niiK. 

vcn. 

■>4.!i 

r)7  4 

t'i(i.7 

-.4.1; 

d"). 

5S..-) 

li-.'..i 

'ill. 

.5-..(l 

.'iii,."i 

4S. 

.Ml. 

(1.1. 

17.7 

1 1 . 1 

."i.').."! 
fill. 

'ill  '1 

:!7.ii 

a-iw 

114. 

41.7 

111.7 

4.t..'i 

.17. !> 

4.-..n 

."i.'i.H 

(!4. 

."ill. 

114. !» 

.'17 

5S.S 

ll-_'  s 

(IS 

iii;  11 

:i..i 


i:xnii:rio\    i\    nokmm,    ivmviiirMs    wn   vM!i\Tinvs   m-pt'vnrvT   o\ 
Mi:Tiions  or    \nMivtsTri\Tin\ 
TliP  pxcrption  lins  bpon  studied  in  several  Ininilnd  rmrinnl  mdividunls 
Tn  our  enrli'T  work  sulirntnnenu=  adniitii-tv.atinn   na-   n-ed   I'xclnsiveU . 


tlie  lii-ii^  :i|i|K'aiin,i:  m  lln'  uiiiH  m  fiuiii  tivi-  U>  cli'veii  ininute.-.  10  to  fiO 
[n'l-  n  nt.  (avi'niL:i>  "iH  pti-  rent.)  hiAuiX  c.Nci'cti'il  in  the  iir>t  limiv  afror  it< 
apiRiiramo  in  thr  luiin'.  anil  00  to  85  per  cent,  for  two  hour~.  In  health 
the  elimination  i-  fiiaiti.  allv  runipleteil  in  iwo  hoiir>,  only  a  I  race  beins: 
pre^enr  iliiiitiL:'  tiie  tliiiii  and  fouilli  li'iuis. 

On  aecouiu  of  the  iar.ue  variation-  in  cm  letion  in  normal  imliv  iduaU 
following  siilieutatieou<  ailniini-tralion.  it  \\a-  tliouiilit  a  iai.'e  paf  .,' 
thi-  \ai-Jatinii  mi-hl  Im  dii.'  to  tavdiiie--  of  ali^orption.  The  oxere  ion 
following.'-  intrniniiMiiiar  (gluteal  and  lninl)ar)  injeetinn  wa-^  .  oii-eqnently 
invest icatod.  After  .<;liileal  injection  (thirteen  readiiiL'-  in  twelve  indi- 
viclnals)  variations  fiorii  11.^  to  (i'?.."i  per  rent,  were  eiieoiintered  (Tal)le 
1)  for  o:ie-hotir  roadin'.'-  (ten  minnti-  lieiiiL;-  allowed  tor  tiino  of  app'ar- 
anee).  an  averncre  of  .ll  per  eent.  heinir  elirTiinat'-d, 


i  lun;  J.  <  ui\e  (.1  i'\tii'I  ion  in  ;i  mi.mi  iov  on>'  li'Mir.  f-tiiiiatiotis  l>tMni.'  made 
at  tin  niinnli'  iiitmal-.  Ijijicr  lilail.  \\ur  ir|ir.-iail^  i'\iTi-tion  folliiwiiift  intra 
viimn-  i!i|i'.inin.  iiijpi  r  dottod  line,  I'scntinii  fiiliinvinz  hiinliur  injection;  lower 
iilack  line  exeri'tion  follouinj;  jrliitenl  iiiji'iiion.  and  tin'  Imwit  dnttcil  lit:"  ,epre- 
•.I'HI-    e\cr('1ion    follosunL'   ^iilienlnnedii-    inject  ion. 

In  tuint\ unr  leadini:-  on  lonrlern  iii'iinal  individuals  lla'  variati<in 
follonim:  liiinhai  'injeilion  ('I'uble  3)  wa-  fioin  ,"il.s  per  eent.  to  (i-l.t 
per  rent  .  e\' i  pi  III  Ca-o  lo.  in  ulmii  tin'  lir-l  test  read  40.2  per  eent., 
and  there  heini:  .-onie  doiiht  as  to  ihr  a  .  iiiatv  of  the  teehnic.  threp  sub- 
pcipieiii  iniiliol  iiiJiitioM-  Were  L;i\in  -liduiiiL.'  ail  output  of  from  tiO  to 
C>\  iirr  c  cut.  oil  i-a.  h  m  <  a-ioii  The  ave-'nge  <iiitpiit  of  the  tweiitv  readinifp 
W.I-  "*,"i  per  M'l,!.  Thi-  would  '^e^ni  to  indicate  lliii*  nh'<'-"-ptin<)  pln}/^: 
liul  a  tiniull  ri'iU-  in  ntjriliiii!  tin'  ii  •  iini'i/  of  the  trxl  nhi'n  onr-hmiv 
dfti  rniiiiniiiiiis    fiilloiilini    inlniliinih'ir   in  ji-clnms   nrr   iinfJoi/rri. 


0     m 


?! 

Tmiik  -2. — Tntkami^i  I  I  Mi    iN.iunnN;    I.rMii\K 

I  ase                                  'lime  nt  — ri'rcc!it;i;;i'   l^xcn'l' 

\;.|  i-araiir.'.  Nt  Half  Jii.!  lliilf 

Minute-  Hour  ll.mi 

I.  (; 8  :i.j.7  li!-l 

:.'.    U 6  i:i.-J  :!').: 

;i.    o 6  ■i'>.'<  lilt' 

4      S 7  :i-.5  -1> 

5.     C                                  7  '^2M  JiJ.:! 

(i,     M.  :f-'..-i  J  1. 7 

7.    V.   .                      :  M.:^  MM 

s.    N.     ,                      li  :i:i.:i  ■-!i'-'< 

II.  .1.                             -i  -J'.i.  J."). 
In,     M.                            7  -j:;  I7,J 


11.    s. 


12.     O. 

in     K. 


u.    (I.   ..   . 

.\vmijzi" 


:ts.h 


•J4.4 


I  IImui 


.->1.(S 

Ii2.4 

r.4..'i 

.58.' 

.-.4. 

,^>4.3 

.i2.0 

ii;!.I 

.">4. 

tn.J 

(ill.'.t 

tin.i 

nil. -2 

i;i.7 

iii.i 
i;a.-.' 

.-.l.H 

t!2.."i 

111).-..' 

.".7  1 

1  .Mil  i; 


I  N  iii.\vi;m>i  ^  In.iiiiiii.x   in   .NiiiniM    i  \.--i  ■ 


(  «Ke 

1  iiiic  '4 

-   I'.'i 

i.'Ill.lL"'     I'A.'II 

|i.,i    .^. 

\|>l)eari»nrt' 

M  Half 

■•m.I  Half 

1  Hnni 

1.      1 

Mitiiiti- 

HcMir 

."id  S 

lluiir 

■j;t.:i 

HD.l 

IV     U. 

1  . 

■t 

.■i:t.j 

lll.H 

ti4. 

3.     S. 

li. 

1 

lai.t; 

1  .•t.4 

SO. 

4.      I< 

70. 

5.     .■<, 

3Vi 
4 

1 
1 

112..'. 
(12.5 
(13.3 
70. 

7       1. 

."is.s 

1  :).2 

72 

V         1 

Ii4,l 

1  ;{.s 

7p 

',1       s 

■ 

4li.7 

11.1 

57.8 

1(1.    .1. 

.15.5 
ti2.5 

10  J 

tl4.5 
72.7 

11      1' 

tf'/i 

tltl.U 

IJ        M 

4 

112.5 
115. s 
(15.5 

l:i      ^ 

1 

(12.5 

1  1      ^ 

\m-iii(;i- 

4 

71.5 

(iR.n 

i!7.f' 

*QiiO«ti)'t»   as 

t(i  Ix'iiii; 

noriiiiil. 

Itiiriivriious  iiijcitioiis  \\n\v  lirpii  >iii|iliniHl  ('I"iitilp  •'!)  with  three 
hhii-  HI  viiw,  namelv.  in  order  to  (Iptermine,  first,  tlie  total  excretion  for 
one  hour;  swnnd.  what  vnriation-'  in  kidney  fiin<tifin  existed  in  noriniil 
individual!';  and  tliird,  to  wlmt  extent  nlisurption  wn-i  n-spnnsiblc  for 
variations  in  excretion.     The  output  for  one  hmii    (Iwrnlv  reiidinf^  in 


» 

t'ointcL'ii  iniliviiluai:^)  nvoiayeil  til.'.i  [ky  lOUt..  ( oiijiderably  higher  tiian 
that  lioiii  iither  iuoti;od»  of  aihiiinijlratioii.  The  excretion  varied  from 
(;-^..">  to  hU  per  tent.,  with  one  exception,  Xu.  9,  who  excreted  57. 8  per 
mu,  Tlii.-  individual  sravf  a  ?oniPwliat  low  o\it|nit  following  all  methods 
of  administration,  alllmu^iii  no  otliM'  cvidincc  of  renal  disease  rould  he 
di-covereil. 

Table  4  -Ika^^^  tin  varialioo-  in  iienenlage  excretion  for  one-hour 
periods  in  the  same  individual-  lollnw  iivi  -uhi  iitaneou-;.  glutca!,  lumbar 
and  intravenous  administraficn. 

TAIU.K      t  --KX(RI;TinN      !>       NdllVIAl.      IsmMhlWIS        lolU.WlMi        I'orli       UlltKRK.ST 

Mr.riiiius  OF  .\t)MiM>i  k\  nn\ 

IntraliiUM'ul.u  ln(  ravcnnii:! 

^t=        §„,,         iy'"''^'--^  =t^         ^^         1^         it? 

8  l.i  Ih    !"    ^"^    I-    -"^    ^"J    1- 

1  ~  I  5;[  .1  ,;"o  .-,  '. Ii4.1  l;i.S  77.!) 

.,'      I,'  •-  _--^^  .^^  |,,,^  _._, 

3'.     s!     '.'..'.'.....    ;i5.7         47..1  ■••■  ■*6-7  II  I         S"« 

4      S  i>2X,         .51!  7  ''--^ 

ti'.'.f) 

t!:i. 

8.    s.  1! lis^s  -iiif.        i:i.4        Hl» 

6.    u 4i,i;       .....  :^>i>       -i^-'       80  1 

7      M  "■-■ 

4:t.i        4:!.i       :!J.:!       •ii.7       .""i.  "■'•*' 

58. ■<        ,   ,         :):).:!       Ji.         .i^  :i  ''"■•■' 

S.     S ■J-2.7  17.1,  •!-••"' 

n      V                         tin.il  11.7  Jil:!         21'.. H         o-.'.(i          ..                             •If' 

44.:!  ....  '"^-S 

4.^1.5  ...  

Ill     i;  I'-'.        ■')7.7 

By  stuihing  the  curve  of  excretion  (riiart  1  )  for  tivr-  and  ten-minute 
intervals  it  was  found,  however,  that  from  '-W  '"  :!■"  per  (ent.  is  excreted 
in  the  fir-t  tw  minnt.-  iifii'v  .ippearan.  e.  this  being  half  the  total 
excretion  fnr  one  liour.  Il  al  on.  e  lieeonii-  apparent,  this  being  true. 
that  obser\aiioM  for  one  hour  nei  i,  .K  ;iie  -ubjeit  to  the  sani"  oriticism 
that  would  appl.v  to  observalion  o\er  four  or  five  hours  foilowMi£;  sub- 
rutancous  injection  or  a  study  of  total  excretion.  Wli.n  intnivmous 
administration  is  employed,  observation  for  more  than  fine-half  hour 
should  not  be  used,  the  amount  of  excretion  for  this  time  being  almost 
equal  to  that  for  two  hours  following  the  subcutaneous  injection.  It 
has  vet  to  bo  determined  if  the  same  reliam  e  ,an  be  placed  on  the 
intravenous  readings  n-  can  tie  plaei-d  on  the  subeutaneou'^.  or  espciallv 
on  the  lumbar  method  of  administration,  as  well  as  what  decrease  in 
excretion  occuri>  in  dicraiie  following  the   intra\enous   admini-tnition.f 

tKurthrr  InvcM ijjniion  lius  olinwn  ili.it  lie    iTilT:iv,.ii,.ii.<  iie-thod  of  Hdministrn 
fioii  i«  not  H«  nocurntr-  in  the  intr.i'iiii-c-Mlnr.  ...4i.eei,ill>-  ^vll..|.•  in.'t.T  (■nlL.ti  r-<  ar.> 
employed.    The  nnrtiml  viirintinnn  in  tlio  fiinrtionite.'  i"mfT  fer  -noli  '•tiort   periodn 

Of.'--,-.    -.,.;!-.::fi^i    :;:■    r.r.f  \:::\f    h:ilir    STf   tOO    LT""* 


lu 


iifi'il  !)»•  '!iii!itii-:  luivo 


The  ^t^iklIlJr  nijiidity  of  cliiiiiimtioii  in  iln'  rn>i  iru  iiiimiti.'^  lii'ldwin^ 
intravcnoii?  injection  result.-,  of  ronr?i\  from  tl'.p  conrentriition  of  the  'Inisr 
in  the  ciiTukition.  cacli  ciibir  centimotor  of  bloocl  <ioin,<r  to  the  kidnj^y-collF 
caiivinj:  mnro  plithnlrin  tlian  hv  any  other  method  of  adminish-rttion. 

rui:  iM'i.rKM  I-;  or  vvitiors  niriti;iics  on  tiii:  i:xci!rr!(>v  hr 
siii.i'noNM:i'innAi.i:iN 

Because  of  tlie  fact  that  many  of  the  iiationis  on  wliom  the  functional 
test  is  made  are  rciial,  caidiac.  or  cardiorcnal  ca^e-:.  and  therefore  tlie 
subjects  of  an  imiuced  diuresis,  it  becomes  at  once  desirable  to  knew  "hat 
influence  these  various  diuretics  exert  on  the  ^ecretion  of  the  drui  in 
the  urine:  or.  in  other  words,  what  cluinjres  in  renal  function,  a--  indicattnl 
bv  the  test,  occur  undcv  the  intlncncc  of  diuretics  and  to  .vhat  extent 
tlu'se  changes  occur. 

A  studv  of  til.'  inlliicMir  ul  uiuifUr-.  is  of  value  from  another  jjoint 
of  view,  inasmuch  as  the  processi>s  whereby  diuresis  is  induced  vary 
considcrablv  with  the  ditfeient  c'nsiies  of  diurctiis.  consequently  allnwin.!: 
inferences  to  be  drawn  reiiardinc  the  mechanism  of  excretion  of  sul- 
phonephthalcin  from  the  infiuence  these  various  cinsse?  exert  on  its 
excretion. 

Two    metlv'.'-    "'    •.-.•.••<;ii!e>  •■    P..     n-IIlK  nr 

been  \\fei\. 

I.  The  '•llfcl  of  iheii  adinit;i-liali(iM  nt\  the  out|nit  of  M.lpiioue- 
phthnh'in  in  cat*  which  received  a  constant  inflow  of  «ultihononhthulpin. 

The  method  here  adopted  wa=  as  follows:  fat-  were  lishtlv  etherized 
and  L'iven  hv  >toniach-tubn  O.2.".  ^m.  thlorhutanel  (known  coniuierciallv 
a«  chloretone)  per  kilo.  fTlic  c-hloihutanol  wa>^  limdv  .nnund  i'l  a  mortar 
and  then  washed  into  the  Momach  with  .".n  to  TOO  c.e.  of  water.)  The 
eats  wcie  allowed  lo  come  out  of  the  influence  of  the  ether  and  were  not 
used  until  one  and  onc-bi.lf  or  two  hours  had  elapse<l.  Into  one  femoral 
vein  was  inserted  a  <an;iula  whieh  wa-  attaehed  to  n  burette  filhd  with 
a  solution  of  phenolsulphonephtluilcin.  Into  the  other  femora!  a  cannula 
attached  to  a  three-way  stop-(ock  wn-  iiiscrttHl.  After  tyini;  the  neck  of 
the  bladder  a  small  glass  cannula  with  a  capacity  of  only  two  or  three 
drop-^  wn^  tied  into  an  opening  in  the  bladder  in  such  n  wnc  that  the 
open  flanfied  edge  of  the  canniihi  lame  in  apposition  with  the  two  ureteral 
opening",  the  apposition  heinp  Fueh  that  in  many  instances  on  com- 
pression of  tlie  bladder-wall  ever  the  t)ell  of  the  cannula,  not  r.  drop,  or 
at  motJt  only  one  or  two  drops  of  urine,  could  be  pressed  from  the  di=tal 
end  of  the  cannula.  The  abdominal  wall  was  dosed  except  it  ilie  ..\it 
of  the  bladder  cannula  and  an  im  :inde-'(ent  electric  lipht  was  placed  just 
a  few  inches  above  the  animal,  the  whole  bein?  covered  with  a  'arse  towel 
in  order  that  the  body  temperattire  be  maintained. 


11 


Uiuler  >urh  condition^  iL  was  U,i\ud  that  an  oMrliciiI  uiiiKuv  Kvittion 
,uiild  IK'  ruii-tamly  obtained  tor  loiij;  iieriod-.  Manv  .u  tfu_.  animals 
iiaviiig  btvii  -ivi-ii  anotluT  siiiall  do-f  cil'  clilovoton,  i,.-Hl:rr  w  itii  hot  milt; 
by  stomach-tube  at  tlie  end  nf  a  (hi.V.-  expi  rinicnt  weie  lound  in  -ueh  good 
i-ondition  the  following  nioinin-  that  (.h-ri-\  atiun-  uvi,.  .niitiiiiiod 
tlirougbout  tlie  second  da\. 

From  iho  burette  liu-  Milutinu  ..f  -ulphoncpbthalein  was  allowed  to 
run  into  tlio  femoral  \ein.  (i  wj.  of  the  dru;:  i)einj.'  administ.  red  at  tiie 
lirst  injection.  Tiie  jihthalein  was  dissolved  in  either  0.8  per  cent,  salt 
or  in  IJinp-rV  >oIntion.  in  -ome  in.~lances  D.O  nig.  to  i.e..  in  others  2  mg. 
10  th.'  <■.'■.  'i'lic  timce!a|isiii'.'b-i'ore  the  aii|iearanii' of  ihecjnig  in  the  urine 
was  noted,  this  WnuiS  usually  from  one  ami  ono-half  t.)  four  minute?. 
Collections  were  then  made  usually  for  lifteen-minute  periods,  oeea- 
sionallv  for  twenty,  and  in  one  or  ,w(i  instances  for  one-half  hour  periods. 
.Xt  the  end  of  each  ])eriod  the  receptacle  into  which  the  urine  drained  was 
changed  and  >ulphonepl)ilialein  wa>  again  allowed  to  run  into  the  vein, 
a  constant  amount,  u^ually  l.S  mg..  for  each  ].eriod.  Where  the  period 
of  collection  was  longer  the  aniouiit  of  plithak-in  injected  was  of  course 
greater,  as  for  instance  in  Kxperiinent  v'M.  the  amount  of  phthaleiu 
hiiected  'ar-h  period  being  ^^  mg.  in  !..">  c-.c.  Kin'ier's  Milnth.u  and  the 
period  of  each  cotlfclion  one-lialf  hour. 

Ccdlections  were  made  for  three  or  lour  such  )ieriods  piiov  to  adinin- 
i^^ering  any  diuretic  in  order  that  an  idea  of  the  average  excretion  for 
each  period  could  be  bad  f.u-  comparison  with  the  outiuit  under  the 
inflii.iiceof  the  diuiclic.  It  wa<  found  tluit  in  some  instances  the  output 
.if  ]ihtluilein  remained  approximately  the  sime  over  periods  of  one  to  one 
and  one-linlf  hours,  although  ihe  .miput  -d"  urine  varied  considerably. 
'Ihi-  diuretic  WHS  now  admiiMstcml  Ihiougb  the  other  femoral  vein 
and  its  influence  on  Ihe  amount  of  urine,  the  amount  of  sulphone- 
phtlmlcin  as  e*^tiniated  by  the  nnl)osi(|  colorimeter  and  on  the  reaction 
..r  (he  urine  noted  (suliilionepbtlialein  serving  as  tlie  indicator^,  observa- 
ijon  in  nniny  instances  covering  a  period  of  four  to  cidit  hours. 

'!"he  ai'companying  charts  rcpicsent  the  results  obtained  in  some  of 
the-e  e\periments.  I'ach  period  lasted  (ifteen  miniitcv  nnl.-.  otlicrwise 
stated. 

CdfciH.— Tliis   fxort'*   a    stimulntintr    inllueni "    th..    -nrotury    celN   "f    tlie 

i.iiiil  f  ilintos  ami  im-roa«.'s  lli-ir  «rcn'tinf:  ihuvov  .  v,mi  S.lirnp.lrr."  .Viitoii."  Arli" 
Mi.l  Siilli-"  Imv.'  <|.iii(iiiMriil(Ml  tl.U  iimiiH-'tii.iiiil'l.v  for  111.'  finHV  kiiln.'v  i.n.l  tti.' 
.,•111.'  picsumnlily  l.ol.l.  for  niainniiil-..  In.loul.t.-uly  it  i-^  Irup  tlmt  nthnr  fiiotor-, 
•iirli  ii«  rtiniiiic  of  blorul  pi.-iiiin-  iiii.l  inrrcHsp  ;ii  Kit.      ''  " •' '■ 


.\iiii.   f.   .•xp. 


l'..ili 


I'l.MlII! 


11.  V.   Sfhropdcr 
xxiv.  «.'>. 

12.  .Xnl.'ii:    Ai'li     inl.iTKif.  'I"'  pliarinac.i.lvn  .    I'.mi.  vio.    t.i !. 
n.    \,'h:    Ai.li.  f    .xi..'!     I'alli.  ii.  I'liarni..  lOOO.  xliv.  .■till 
M    (  iilli<;  .lour.  l'li>-i..l  ,  ItlOil.  xxxiv 


f   ll.iw  tliinliull    the  ki'llli'S 
ISSC.   x\ii,   :W.   mimI    h-*: 


I.W. 


#  * 


12 

(Aeli."   ricli-licM.  Uciiili  i-nii  anil   l.oi'Ui'  ,i    arv  ;hl(lii  iiiw  I  mihI   iiii|ioi  t.ni;   tacti.rs  In 

111.'    |M.i.!iii'tii'ii    ni'    diiin-i-.      11 xcri'tinii    .'I'    tin'    -mII.U    niniiT    tlir    iiilhiriifi'   of 

.Mill  111  i\nii  S.-li:no(h-i.  I.oi'wi'  )  .1^  «i'!l  lis  till'  uiitiT  niitpiit  i-  aiiL'iiieiili'il. 
I'liiiTofl  mill  Slr.iulr'=  -iiiiu  tliiit  there  i-  ii  ti'iiiiioiary  iiieriM-r  in  IIh'  iiirlabci|i-iii 
lollnwril   1a    a   divira-i'   iiiuli  r  tlir   inlhiiMii'i'  (if  tlii~  ilrii^'. 

riii'  ciri-ci  of  callViii  nil  'lir  rxcroticiii  of  siiliiliDni'plitlialiin  i>  iiulicatcil  in 
r\|.i'i  itiicnt  11.  (  liait  :i.  I  111'  aMTiii,'?  outpm  inior  to  tlii'  adniinistratiun  of 
lairoiii  \v:i-  1.-  iiiL'.  for  I'licli  lifti'in  niiniili's.  ami  after  tlio  aJniinistiation  1..') 
ni'_'.  lor  Mir  -anil-  Iriintli  of  tinir.  Maiki'il  iliiiii'si-i  iiiidiM-  the  inllllcnei'  of  eafleiil 
1-  IliiTeforc  as-iiiciateil  witli   an  aiipn-cialilc   iiicriiii-e   in   tl'i'   plitlialiin   oiilpiit. 

Siiiliinu  Cliloritl. — A  rational  explanation  of  saline  diuresis  is  that  advanced 
l.\  I  ii-lmv."  Tli;^  [irei-cni'i'  of  liypiM  tonic  sodiiiin  ehlorid  in  the  hlood  disttirli- 
tiii-  ii-iiiot"ie  rclatioTi^liip  iiiiil  i.-iilis  in  a  ijieat  irillnv  of  water  into  the  blood  from 


.<t-   . 


V 


(  hart  H.-lAp. ■11111. ai'  M  (ai.  i  him  ii.ilaiiol  am -i  la-i.i.  I  iill.ii  m  i'  oi  .all. Mil 
on  urine  output,  phthalciu  ixcrition  and  reaction  of  llie  urine.  In  this  and  the 
followiii}:  ihiirti  the  line  with  solid  dots  indicates  c.e.  of  nrine  per  period  and 
the  line  with  reef.inu'Ies  indicates  ni;:    of  phtlialein  rv.ri'led  per  period. 

the  Ivnipli  spaees.  hydremia  resullinL'.  The  hydremia  caVis  an  increase  in  the 
lapilhiry  pressure  in  the  yloineruli  which  in  turn  promotes  the  escape  of  lluid 
into  the  capsule.  Ilie  resiiltinjr  ililuted  urine  rapidly  (lows  throiiah  the  tubules. 
a    short   time   only    bein.;   presented    for   leabsorption.   a    marked    increase   in   the 


IR.  r^wwi:    .\rcb.  f.  .xpei.   Path     ii    rii.niii..   UUi.-..  !iii.   l.'i. 

in.  Loowl:    .\rch.  f.  exper.   I'alh    u     I'haiin.    lIMiJ,   vMii,    til, 

IT.  Rnrcroft  and  Stranb:   .Lair.   Pby-i-il  ,    I'.ll     \li.   1  l-"i 

IX.  (■ll«hnv:   .Iniir.   l'hy«iol,.   Iini.  xxvii.    11"    .ml    I'H'-'.   xxviii.  411. 


.iiucnim   .'1   Hi  ill.-  MrrcUMl   thcich.iv   n-ull-.      I  hi-   i-  a   |iUivl>    lii.vliiiiiir.il   procoss 
,in.l  can  bo  rcproihu'i'it   jioiiit   for  |joiiit   in   tlie  dead   animal    iSollmanni. 

Hypertonic  sodiiini  clilorid,  oven  wlien  the  diuresis  i-  ennrninns.  eau^es  no 
increase  in  output  of  sulplionephtliahin;  indeed  the  avera;:e  output  for  fifteen- 
minute  ijeriods  is  sli^htlv  .hrrea-ed  from  1.2.-)  mg.  before  to  1.15  m?.  after  the 
administration  ((hart  4.  KN|ierinicnt  12 1.  We  l<no\v  tliat  tlie  output  of  sodium 
.hlorid  under  tlie  eondition<  of  tlii<  e\perinicnt  is  <;rcatly  increased  ami  tlierefore 
conclude  Hiat  ll \civtion  of  phtli.ilein  bears  no  relation  t-i  soilir.m  elih.rid  excre- 
tion. 


t-\ 


(O 


o 

« 

c 


^    '#- 


m 


N 


o 

t) 


\  o       o 


V 


o 


(hurt  4.— Kxpcrimcnt  IJ.  i.'l,  l  hb>ibutam)l  ane-the-ia.  KlTr,  i  of  Midiiini 
rblorid  and  urea  on  urine  output.  ]dithaleiii  excretion  and  reaction  nf  the  iinnc. 
In  addition  to  the  lino  already  cvplaiiicd  Ih.'  .loublc  line  in  Ihi-  ;ind  Inllouuif.' 
charts   indicates  distinct    alkalinity  ■>{  tie'  mine 


iccM  lliiin-iil  to  |iiiMlncc  diuri-'i'' 
I  by  salt  iicii<'n  Ihe  work  of 
hows  |li;it  ill  the  frog's  kidney. 
when  only  the  tubules  are  allowe.l  to  participate  in  the  fornK.li..n  of  urine,  salines 
fail  to  produce  diiircsi.'.  whereas  urea  elicits  an  almndan!  secretion.  This  cer- 
tninlv    oidiciilc^    tliat    the   .ictbm    of    iinii 


r,v',i— I'lca  li.'iii'j  ,1  ,lillu-ib|.'  -iib-tan.v  ha--  1 
in  till'  -:une  manner  .w  -oiliuin  clilorid.  that  \- 
(  ullis.  however,  which    wc  are  ,iblc   to  confirm.  - 


itTer- 


inmcwhat    from    that    nf   -odium 


^'   0 


14 

cliloriil.  ill  fiict,  it  indicates  tliut  tiioa  i-xprt<  ii  stiiiiiil;itin!;  ofToct  on  tlie  cells  of 
the  renal  tiilmli'^  just  as  cafTein  iloe<.  l-'iiitiieimore.  Barcroft  and  Straub  have 
shown   tliiit    diiiin'i  in  r.i    diiirej-.  m"vr  than   the  iimiiial   anioiinf  of  wor';   is  per- 


«^ 


('halt 
111  ini'  "!il| 


.'..  —  lAii.iiniMil    Is.      I  i.t.   (  lilni  liMUincl    :uii'sthe-ij.      l-:ili'ct    "i   iiren    on 
111,  [ilillinlcin  eM-ji-iinii  and   nMctioii  of  tlie  urine. 


<  Imrt  0. — Kxperinieiit  -ii.  Cut.  (  lilorhiitanol.     i;ir«rt  ■  I  de\iio-e  "n  urine  out- 
p;ii.  phthaicin  txtnlion  atrj  ieaeli*»ii  of  iuin*- 


«l 


15 

furiiii'il  h\  tlic  I'.'ll-  III  i!ir  liii.iili'~.  till  MU'li  iticiiM-L'  lirin;.'  (li'inoii-tial)li'  iluiinf.' 
tlic  coiirM'  lit  :i  -aliiir  iliiiii-i-.  rill'  fact  lliat  uifa  increases  tlic  excretion  of 
sulphiiiioplitlialciii  uhilc  suiliiiin  clilnriii  does  not  iniliicnce  it  at  all.  or  decreases 
it,  al-o  nupgcits  llial  a  ililfprencc  in  tlic  nietlioil  of  action  i'xi-l<.  Whereas  in 
our  experinient-  i-mlimn  rliloriil  ifmrc-is  was  acc<iinpanied  liy  tlic  early  appeaiance 
of   alkalinil\    uiiidi    pn-i-tnl    fm-   a    Imi;;   iiiTiml.    alkalinity    «a-   uhtaincd    only 


(  hart  7.— Kxpiiiiii'iit  ''•.  lai.  (  him  liiilain  il  .1  tic^tlicMti .  KlVcct  ul  calimtcl  i-n 
urine  utitpul.  phlhalciii  rxn  ct  iim  ;iiti|  HMctinti  ni  urine.  Kach  pet  iml  twenty 
minutes. 


(hart    .s.- -lApri  inient    JO.      lai.      (  him  Inil.ninl    anesthesia.      KiTect    of    pntas 
siilin  acetate  on   iinr Ipnl.  phlliah  in    ■Mretimi   anil    reaction  of   urine 

will nsiileiahlc    dillicnlty    iltiriiiL'    Ihc    iitci    .iiiitr-i..    which    i-    another    point 

indieatinfl  ilillcrciice  In  methoil  of  aciimi       in  "i xpn  iinciit    ((  halt  4i    a  slight 

decrease  in  the  phtlialciii  excretion  under  the  inllucnce  of  sodium  chlorid  and  at 
the  same  time  a  slojht  increase  umlei  the  inlliiencc  of  una.  while  Chart  .').  another 
experiment,  shows  ti  vciv  ileliiiile  incna-c  in  phtlialein  mitpiit  under  .1  una 
(iill!-p.i^_     'nil.  ijifrpviiir..   in   llii'  .il!,.ilinit\    in   tin    luu  lAperinient  s  is   .^tlikiltL' 


4'-» 


16 

/,,,,,„«• —IVxtn.sP  ivx'iiiUcs  iirwi  cIom-In  in  lt~  ;ulini!.  !l  is  ul>o  rapable 
„l  -liinulatiii-'  soeiftion  l.v  tlie  tubules  in  Ik.--  ;.-  «os  -h.i\Mi  l.y  (  ullis."  Hiart 
li    ;-:x|»TiiiiPnl  L'-J.  in.li.iiti-  ll.i>t  it  ills.)  -li.^litly  imiva-,-  tli,'  phtlialeiii  cxciclion. 

(•(i/omc/--l  almml  is  fla-iliid  as  au  irritant  .liurvtio  raisin;,'  the  ^loincrular 
pressuie  l.v  .lilalin-  H...  reii.il  arfri.il. -.  It  possibly  »tininlatos  ;,!-,.  the  vital 
'ecretorv  inn.tion  ..f  M.,-  r.M.al  .rll-.  Thi.  latter  is  su-M-t,,l  l.y  ih..  .W.uUni 
increa-e' uf  j.hthalein  excretii.n   in  <  liart  7.  Kxpeniuent  >>. 

/'oaivMii".  I <■«.(«(-;.— Altlu.u^'b  this  is  Mippo-ed  to  exert  only  a  salt  ^i,t|..n.  it 
will   be  seen   tr-.in   dinit    S.   lA|.erini.'nt,  -Jll.   that   an   increased   plithaleni  ..ntput 

was  elicited.  ,  , 

/)i,;i((i;|-,s-  l)i"italis  proiiuces  dinrr.si-  .■ntir.-ly  through  circulatory  chan^'e^. 
i  ,.  jiaiv,-,.  in  heart  action  and  increa>e.l  blood-ni.ply  re^.'ardless  of  the  >li^'!it 
w.-ue.nistriction  uhicli  accompanies  its  use.  The  solids  may  not  -hare  at  all  in 
the  diuresis  Thev  nniain  the  -airie  or  at  most  are  but  slightly  increased.  The 
,,1, tint,  ill  ...itpiu   'in,-  11"'    inrrca-  im.hT  He'  inllii.'n.-,.  „f  dhjitali-.   in  -erne  ease» 


(  liart  !!.— Kxperinieiit  S.  i  ai,   '  hlui  hiUai.nl 
iiiiiie  output,  phthaleiii  eMTelinii   ..ii  '    n.oii.'ii 


111. Ml.. 
.1    til.' 


r.ir.' 


4    .linilllill- 


lUiiteicil  durin" 


reinaiiiii.^'  the  -aiiie.     In  one  in-taiii-.-  a   ih'.i.leil  deerea.se  \\a- 
the  course  of  a  niaikeil  diuresis   (Chart  !•.  Kxperimcnt  (>i. 

P/,(or/ii:;.i.— According'  to  Loewi"  this  is  not  a  .lireci  .iiiii.ti.'.  liie  diuresis 
really  reMiltiu^'  from  a  loss  of  real. sorption  power  in  the  tubuh-.  lullis,"  on  the 
other  iiand.  shows  that  it  has  some  direct  .stiniidatinL'  elVeet  on  tlic  tubules  ami 
,d»o  Hint  l.v  |..'rfii-ini.'  it  through  tin  Irog-s  kic-ney  a  reducins  body  can  be 
i.l.tain.'.i  Ihi-  work  of  Harcroft  and  Straub"  aNo  indicates  that  tin'  socretion  is 
an  active  process.  As  will  be  sc-n  in  I  hart  10.  Kxperimcnt  -JS,  a  sli^dit  increase 
from  1.7.-)  to  LiK!  m^'.  for  one-half  hour  [.iriods  was  obtained  followin2  its  use. 

h'i>iii< r.t  Sob, lion. —OnW  a  sli^iht  diure-is  was  obtained  with  Uinjier's  solu- 
tion (see  t  hart  11.  Kxperimcnt  -Jl).  and  at  tli.'  -.iiiie  time  practically  no  efleet 
on  the  phthnlein  output,  frea  in  this  install..'  di.l  not  increase  the  phthatein 
output,  this  hein^'  the  on.-  instance  in  live  ixperiments. 

Polnasium  .ViVinfr.-rnder  the  conditions  of  the  experimi-nt  this  s.,lt  iirodiire.l 
.liuresis  while  sodium  nitrate  faile.l  on  several  occisions.  The  potassium  mn 
mn.t  therefore  plav  some  r.-.le  in  the  production  of  .liiin'sis  as  well  as  the  nitrate 


19.  Loewi;    .\rcii.   f    '■vp" 


i'atb.  .1.  rhaiir,.  irio.';.  i.  :i2ti. 


V 


17 

i,,„  11,,.  -,,l:  ;i-  M  (IPiietic  f.ill-  iiit"  Ihr  -.mil'  'Jicni.  ;i-  tlir  Mi.liimi  rliloiUi. 
I'nu'tically  no  inlUionc-  is  exerted  en  the  pl.tlmlein  exerotion  (ilKirt  12.  I-aimti- 
iiient  ^ni.  the  ;iviiiip'  output   liefore  anil   after  liein?   l.OS   niL'. 

L'lKk'i-  \\  V  ciimlitinn-  of  our  experiiiioiit-  it  wa?  I'nuiul  ihat  tliOfe 
diim'tk<  wliirh  -Avv  kiiMMi  to  exert  some  stimti!atin<r  influence  on  the 
activity  of  tlie  -ecretin.i;  cells  or  tho>e  dituetios  in  connection  with  which 
pvidoiice  i?  at  hand  indicatini:  a  ^timiilatiiiL'  action  on  the  secreting:  cells 


(  li;,,t  10. i:\iieii;iicnl  j::.  <  .ii.  I'.lVi'rt  of  phlorliiziii  on  urine  ouipiil.  [ihlhulein 

exeretiou   and   renetioii  of   lli,'   urine.      K^u'li    i.eiioii   one-lialf   lioui. 

(rallrin.  inea.  ilextroso.  ]ihIorliizin.  calomel).  sliL'htly  increase  the 
phtlialoin  outiiiit.  wliere.'iH  tho>e  diuretic;!  which  act  entirely  by  changes 
in  osmotic  tension  or  1a  chaniios  in  blood-prcssure.  etc.  (hypertonic 
sodium  chhuid  solution,  jiotassiuni  nilttite  and  diiritalisK  apparently 
have  little  or  no  effert  on  Us  exi-retion. 


#!  # 


18 

Tin:  i:i'i-ij  1-  ok  oiruKTUS  on  i'Htiiai.kin  kxchi-.tios-  in- 
normal  iNDivinrAi.s 
■l'lii>  iilitluil.Mii  .\.ii'lion  inlluwiii-  iiitniiinHi'iihir  (liinibar)  injcclion 
\va>  ftudicd  in  a  mnnbi'i  of  iKUiiial  iii(livi(liiMl>  who  wciv  tin  ;i  given  bv 
mouth  variour-  diuretics  :n  llie  UMial  dosigf  I'oi-  tuniD-lnur  hniiiv 
pievinus  to  ivpcatMig  tlie  tc^t.  'I'lic  crillritions  were  made  lor  one  hour 
following  the  tune  of  apiicaian.  .■  .d'  the  |ditiuilrin  in  llir  urine.  The 
drwj^r-    emploved    wne    d;,L'ilaii>.    ra'onud,    diurctin.    .aireiii.    tlie    ward 


-1  /' 

C" 

■/<i 

.— < 

/ 

c 

A< 

t 

/  f 

o 

/     X' 

\    I 


\  \ 


"i 

''! 
/'> 
(.1 
a 

'7 
ID 

T 
t 

1 
<. 

5 

5 
I 

I 


I  hart   11.— Experinu'iil  21.  I'al.  (  Idoibiitatio!  ain'>llic>-ia.     KfTect   nf    Hir—r'^ 
-nlntion  and  ul  urea  <m  tlip  iiriiiH  mitpul   and   plitlialoin  excretion. 

diuretie-"  usually  .midoved  at  the  John-  Hn..kiii~  lln-pital.  and  Ba-haniV 
mixture  of  iron. 


•4^ 

-  / 

■  (.      ■ 

T-- 

..' 

-  / 

o 

2'. 

"' 

.•"  ' 

r^ 

o 

• 

■=/■ 

c 

V   ■ 

.  t 

■67  ■ 

{': 

o 

e 

a; 
t. 

'   " 

♦ 
/ 

.a.. 

^-' 

--^^-y 

^— ■:; ;.. 

~~4=. -L— 

»'  ■ 

^-t--" 

in    W.ir.l   dini.'ti'- 

l'i>tM--ii    .Vc-etati- 

I  r.    ScilliP    

Spts.   Etlieri*   Nitro-i 
Aqllie  <].   s.  ill  I 
Misc.— Si;r.   3ii   '.   i    ■' 


.iiv 

r.iij 

.'liv 


* 


A.' 


The  iv^ull-  oi.laiiir.l  nr^^   U.  M.ii   in  TM.l.    -V     N-  app.v,  lablo  effect 

,„   phthalrin  .N.nli ouki  l-e  .lelcvl.a   in  any   in^laiuc  with  llu'  onh- 

„a,y   th.iaiHUlu    .lo.-r.      lielativrly    m.uh    Im-.i    dn>..   u.iv   a-,-,!    ill   the 
llllilllili   l\|'tM  uiieuts. 


(  l.Mit   12.-K.xpeiiin,-nt  :i.l.  .at.  (l,l,.rl,uU.iiol  ,um -1 Im.     i:ir,vt   nf  |..,ias^i.in, 

liitratr  ni,  the  urini'  .Mitiml  iiii.l   plitliali  in  .•\iMv1ioii. 


IMMVUTM    -.     IM.IIUW,,-.,     iNUtAMlMllAll      .LlMMMl-       1  SMKr,  ION  > 


Naiiip  Niaiiial 

...  Kxori'tioTi 

I'lT    CTllt. 


ol      I'llTIIAMlN 
DiUKli 


K. 
M. 
M. 

S. 

s. 
w. 


ti:;..! 
i;ii.-2 

C.S.J 
48. 


F.  5rt.4 

S.  4fl.7 

V.  •  (iO.O 

45.r. 

tili.ll 

•SlllirlllilMri.il-     illjirliiill-. 


1  .ilViiii   1:1.   iii.  t.   i.  il. 

Diiin-lin  'jr.  w-  '1-  -•  '"•  '<"    - '  '"■^■ 

i  ,iloiii..l  -1.   1    I'.i.  M-   '■-  '"••  "1'  'f'  '^ 

.loses.  'IVst  1  111-",  afi'i-  last  ilo^e 
Diiiictin  ^'1-.  \v.  <|.  4  lir.  lor  24  lirs. 
Caircin    'jr.    iii.    1-    i-    '1-    f'"'    -->    '"■^• 
!lii-liiunV   iiiivtiii"   .'li.   '|.    4    lir.    f'lr 

•24   In-. 
Ditto 

Ward    iliuu'iif    "iii-   <|.    ■>    l"- 
I'r.   (lipitiili-   111.   Nv.   ||    •''   111     for   -^ 

ilosi'^. 


Iv'icrel  ion 

.\ft>r 
Diuretic 

I'lT    C-l'Ilt. 

ti2.r> 

liD.'.l 
11(1.2 

r,  1 ,7 
1(4.1 
.-,1.5 


.)ti.2 
4tS.') 

111). 2 


Tin;  iNn.rKN.i:  oi^  iiiri;i:M-  "^    mi;  in. a.  ii"n  of  mi:  i^iink 
In  is:y,  Fa!(k='  eallcd  attention  to  1h.>  rn.  t  that  the  urine  heiomes 
alkaline  foHowiiiL'  the  mlirlnHtratioii  of  lai-e  animint^  of  ^a't  solution 


21.   Fnl.'k:    Vir 


,.l„nv'-    Vrili.   t.   patli.    -\nat..    1S72,   Ki.  111." 


#1  m 


20 

l,v  s^toiiiaili  (11-  imravi'noiisly.  (.rubor--  iwiido.l  similar  observation  in 
1887.  In  h\<  work  on  .ailVin,  vnn  SthrocdLM"  encounlored  the  ^ame 
phcnoiiKiion  invokrd  by  thi^  (iuuviu  when  ihe  nerves  to  one  kidnrv  were 
destroyed.  The  urine  from  tlie  side  with  .liun-i-  wa-  alkalinr.  that  Iroin 
the  otiier  side  was  still  acid. 

itiidel.--  in  18!f^.  mad.-  a  .aivlul  study  of  tiiis  subject  working  with 
numerous  diuretics  and  found  that  alkalinil>  very  commonly  resulted. 
KatMivanui'^*  studied  particularly  the  iidlu.-iuc  of  .atlein.  nrea  and 
diuretin  in  this  respect.  I'nder  their  influence  the  alkali,  estimated  as 
'•alkaline  chlorids."  is  .m'eatly  increased,  sodium  oxid  is  always  increased, 
potassium  oxid  nuiy  or  may  not  be  iiurea-ed.  and  these  ehanges  can 
occur  under  the  influence  of  cairein  even  without  marked  diuresis.  Urea 
increase-  the  chlorin  and  sodium  oxid  and  alkaline  chlorids  only  sliiihtl>. 
Diuretin  iiureases  markedly  the  alkalinity,  as  '-alkaline  .lilorids."  .blorin. 
potassium  o.xid.  sodium  o.xids  are  all  imreased. 

A  change  in  reaction  (alkaline  urine)  has  been  noted  in  manx  of  our 
diuretic  experiments.  \Ve  have  noted  it  after  destroyinir  the  iu>rv. 
.•onnections  of  one  kidney  in  two  instan.es  even  when  diuretic  s  were  not 
adtnini-^ten^l      In  two  other  inslauces  under  similar  conditions  it  failed 

to  appear. 

Tnder  the  condilu-n^  of  oui  experiments,  as  .s't  forth  in  the  descrij)- 
tion  of  our  work  with  diuretics  on  <ats.  nlkalinity  of  the  urine  is  indicated 
bv  the  urine  assumin-i  a  purplish-red  .olor.  The  ease  with  whicli  a 
.iuinL'e  in  reaction  is  invoked  varies  verv  eonsiderablv  with  tlie  various 
diuretics. 

Tin-  sn-:cincrrv   ni.si'i.\MO  i:i    nu.   mdskv    in    tiii;   i.x<i!i;rio\   of 
eiiniM.iiN    \M)  Tin:  (•omknthation   . Mwcirv  or   riir 

KIPMIV    IN    Tins    lillO.Mil) 

Six  111^'.  of  phthalein  ]L'i\en  subcutaneously  to  a  patient  w.i-hm-  b(i 
kilo  yields^ft  dilution  in  the  body  of  1  in  lO.OOO.OOO.  An  infinitely  dilute 
^ohltion  is  presented  to  the  kidne.v.  which  within  one  hour  under  normal 
.-oiiditions  pu  ks  out  .10  per  cent,  of  these  eirculatinfr  molecules  and  losses 
them  on  into  the  urine,  sometimes  as  ni.idi  as  3  mjr.  beinp  excreted  in 
12  e.e.  of  urine— a  dilution  of  1  in  4.000,  or  2.500  times  the  concentration 
in  the  blood.  When  the  amount  of  bloo.1  only  is  considered  in  the 
<piestion  of  dilnticm.  the  concent ratiufr  power  still  remains  several 
hnndrefl.  for  when  (5  mp.  is  piven  intravenously  as  much  as  50  per  cent, 
(an  be  recovered  in  five  minutes  in  2  or  3  e.c.  of  urine. 

At  the  same  time,  in  either  instance,  the  same  eoncertration  is 
presented  to  the  liver,  to  the  pancieas.  salivary  jrlands.  etc..  ai'd  yet  only 


"2    finitxr:  T.ii.lttiB  V>Ht«rtirif».  1HH7.  .nmtHl  from  Rtlil<-1 
"»:i    Itll<lol:   .\rch.  I.  exwr.  rath.  ".  ri.nrni..  1802.  xxx.  41. 

:.;■  ".;,,,;„„„.  -/..ni,'  i  ,,i,v,ini.  .h-n,..  m^.  xxwu.  b«-.  \m.  xxxn.  231. 


ij 


21 

a  small  amount  appears  in  the  b.le.  while  not  a  tnuo  of  U  can  be  found 
in  the  pancreatic  juie.  or  saliva.  The  capacity  of  pickm?  out  he  mole- 
cule^ uf  sulphonephthalein  frcn.  infinitely  dilute  solution  and  passing 
them  on  into  the  secretion  in  comparatively  concentrated  solutions  is 
therefore  a  function  specific  to  the  kidney. 

MECIIANTSM    OF    IlXCItETION    OF    SULPIION-EPil  TILVLEIS 

The  ideal  method  of  determining'  the  mechanism  whereby  a  dye  sub- 
stance is  excreted  i^  that  which  was  adopted  by  Heidenhain"  m  his 
work  with  nidifro-carmin.  i.  c  to  remove  the  kidney  during  the  active 
secretion  of  the  dve,  ti.x  the  dye  in  situ.  n,ake  sections  and  demonstrate 
the  presence  of  ^-ranule.  of  the  d>c  in  the  cells  actually  engaged  m 
e.xcreting  it.  By  this  method  he  demonstrated  tliat  indigo-carmin  was 
excreted  hv  cells  of  the  tubules. 

Thi^  method  ca-.ot  he  utilized  in  connc.tion  with  phenol^ulphone- 
phthalein.  as  all  ^f  the  ordinary  fixatives  fail  to  fix  this  dye  in  the  cells. 
Omsciuentlv  it  was  found  necessarv  to  attempt  to  ascertain  bv  other 
methcd.^  which  part  of  the  excreting  nun^hanism  is  concerned  in  the  excre- 

tion  of  this  body. 

EXCincTiON  iiv  Ti:i:  fhoo'.s  kidn'ky 
The  work  of  Nussbaunr"  indicating  that  the  ivn.l  tulmlc  in  the 
fro.Vs  kidncvs  are  ...pplied  by  the  renal  portal  >vste.,..  whu^h  i.  entirely 
separate  and  independent  of  the  arterial  supplv  to  the  .lomeruM.al  hough 
di  credited  bv  Adam,.-  was  later  -h..wn  by  Nus>baum  =  "  and  hv  Beddani^ 
to   be    absolutely    correct.      The    work    .f    CuHh    al-o    atTnr.U    stnkin. 

corifii'ination.  ,     ,       ,     .        .      41  . 

■Vdvanta-e    was    taken    of    tin-    indepcn.lenee    of    cvulation    to    the 

tubules  in  th,e  frog",  kidney,  in  an  attempt  to  di-eover  the  method  ... 

excretion  of  sulphonephthalein. 

■     T.ar.e  ,„ale    fm..   i:.u,„   u„,s}.n„n.  weighing  about    nOO   gm..   were 

i,|,,,l.  t,,..  „,.,l,„nen  opened  bv  Inn-,  inci^on^  en  each  ^ide  „f  and  parallel 

lo  „„,  nnterior  abdominal  vein.     The  left  kidnev  w:w  exposed  and  ah  the 

arter.a!    eeimections    sev,  red    bv    mean«    of    the    l>aque!,n    eauterv.    as 

«u.'m-ted  bv  Beddard.     A  .annuh,  wa-  then   m^.led   into  the  anterior 

abdominal  vein  and  a  .nail   .las.  catheter  in.M     d   int.  the  b.ft  ureter. 

A  protocol   will    indicate  the  course  nf   tl xrenment   and    the   result- 

obtained.  „     ,     .1  1     11, « 

l!i„eer-s  solutien    wa^    perfn^,  d    r,e,n    a    Mar.et.e   th,-k    through    the 

n-nal  portal  ss.t..m  uiehr  a  prcMire  of  X,  e,n.  of  water.     Perfu^on  from 

2fl  N,„.lmun,:   nUlL-r'^   Ar.t.  .  I^T^.  xv.  130.  >in,l  1S.«.  xvn,  890 

27.  .\.!iiii!i;   .lour    Phvcinl..   !«•<•!.  vi.  3S2. 

"•»  Nimlmimi:    Anat.   An7ci.."T.  IS^fi-  i-  B7. 

:il  |l,.,l,!„r,l     .1e„r    l'l,v-     1      l"l'-'.  xxvi.i.  ".» 


nf* 


tlie  renal  }.oiial  vtin  lor  about  liflfru  ^ce■ona.■^  every  three  minutes  was 
l.euun  at  l--.'::iO  p.  m.  aiul  eoiniiiued  until  'i  :■.'■"■  ]<■  ni,.  no  tlow  of  urine 
resulting.  At  2:2',  tlie  same  solutitin.  but  now  containinj:  l-J  per  eent. 
urea  and  also  pllenol^ulpllonepllthaleln  ( (10  v.\'i.  to  100  e.c).  was  per- 
fused. Diuresis  l)e.;anie  ai,parent  at  2:W  p.  ni.  M  :!  •..-.O  ]..  ni.  the  urine 
readied  the  distal  end  of  the  catheter  and  was  found  to  lonlain  umsid- 
,  rable  phthalein.  .\l  1 :1"  i  •  ni.  a  >aturated  aqueous  solution  of  I'russian 
blue  was  injected,  t!ie  kidney  inmieiiiately  removed  and  placed  in  absolute 
alcohol.  Serial  sections  were  later  made  but  not  a  trace  of  blue  could 
be  found  in  any  d'  the  j:!omeruli.  identical  results  were  obtaineil  on 
i.ddinj:  eatlVin  to  Kinger's  solution  during  the  course  of  a  purely  venous 
perfusion. 


Si/i  '  J_i_J::5Lj-.-i-.! L  !z.>-.i...J..i 


_/Q1    13L. 


a  -HI-;  i 


liiip  till'   Mnidunl    III'   .illiMiiiiii    in    llii'   uiiiH'    in   u'liiiii.-   |ii'i    liter. 

Thi?  furni>hcs  ilh.solute  pn.of  that  j.h'  nnhufphdiirplithnlnii  ,  .ni  hr 
rj-rrrlid  hti  nai/  of  the  cfiU  of  tlie  hihnhK  in  the  frog  and  pre^umaldy 
the  same  holds  true  for  mamnmls. 

In  another  frog  a  purely  nrterini  perfusion,  by  (he  method  of  Culli^. 
wa*  made  with  hy|iertonic  sodium  chlorid  solution.  IIim'  aUo  the 
phthalein  uns  pxcn-trd.  bnt  under  tliese  rondition-:  both  tubule^  and 
glomeruli   p.irtii  ipate. 

nu    iNFirK.sTK  iiF   .\\i:mi\ 

Hannd'l  and  Striiuh"  Imve  i>hown  that  nfter  e\.'nding  tb;'  function 
of  the  renal  tnhnlr.t  by  profuse  blecdinir  and  the  adinini-tration  of  lar^'c 
quantities  of  lliuL'fr's  solution,  an  isotonic  urine,  a  pure  idomerular 
filtrate  (an  be  oiitaimd  'I'hr  excretion  of  phthalein  under  mh  h  inndi- 
tionP  was  investigated.  .\  proteeol  of  an  eyperiment  m  tbi-  innneetion 
follows   (Table  i',V 


*y 


23 


tinn  of  0  lii^'.  snlplioiu'l 
„f   phtlKili'iri  \v;i-  ^;ivpn 


.  il.lor.'l.iii.'  :it   10  a.  111.     \-2.-li-<  iiijee- 
^itliaiein  i'ntravrn.m-h.     At  1, :i.l  "i  .'^i^'l'  I"  "."1   1 -S  -i,?. 


Cat.     \\>ij!lit.  -2.^  Ut-'.     liiji-'ti.m.  ".T  liii 


IMlli:    i;.— lACHMllIN    "1      I'lllH  Ml  IN     Al  II 

I  I   |;|,s     IIV      r.l  II  11IN<^ 


B    lAll.l   >I'iN    '11-     I'l'^'   ""^ 


.1    Ri;.N.\L 


Time 


Qiianlity 
(if  Liine 
in  c.c. 

0.6 

0.6 

0.7 

0.6 

n.fi 

II. s 


rUtlialein 

Excreted 

1.02(1 

D.'.l.')! 

l.(l-.ii( 

i}.T8'.i 

(i.ms 

11.714 


1J:):1     p.     111. 
I-':. IS 

l:l.i 

1  ;  ■-■■< 

I  :4t 

1  :ii^_l,|,.,l    ■M.r,   .'.e.   an.l    iiiji'.te.l  40   .ve.    Uilitr-f-  -olntim,    -    iMi 

,„,..   pi.,lK,l.-i„   -Mia.  _  ^^,^.. 

■J:i:.    p.   111.  ;-  ,.,.,s 

'-■'-^  i'3  1.1  Js 

■J -4^1  ,■          ■ 

■>'4-' ■'■47--l'liil  411  01".  am!   iiiieoliii  .'lO  iv.   !!iii^ei  ^. 

','  -Z"  ii.'.l                                      II. Ill"- 

■-■•';'  ,4                                      (».li',i;i 

■MIS  In  :i:12     M.d  :ti>  r,..  an.l  inj.ete.l  ;^n  .•  <■    llhi!:-.-  T   "-'l  '"iT- 

phlliall'ill     i\tl:l.  ... 

:i;4:i  .       ,"•* 

;i^:i  "ivcii   1.')  e.e.  I!ini:er  s  solution. 

ir.-.s "  '" 

.):IIS   ..jix.M   -.'O   ,■.■.    I!in'.;i't"-    -olulioll. 
4:11 


ll.:i011 


4  :  J'.l 

4::i7— i.ie.l  :i:i 

I:  17 


11.4 

US  I'.^lM 

,..  ,,ii.i   'jn'U  20  CM'.  i;ini;.T'-  -olntmn. 


II  !1 


('2711 


,,„„.,  ,,„|,.j,,,,,i   .,,-,a4itr>rnp.l   ^inil   th-'  :nnm;nt  m'  ,,l,tl,a!.in 


]U  I     c  llllil'   <'»''lt  illM'tl'I'   1 

hi 


-tiiiiatnl.  ^lin«i.iL'  tiiiit  tlio  iiniouni  of  ,!■„-  in  tiu- 
W  inrroasoil  o.,i<iilio-i,Mv  .lunn^  the  ,.x|u.nnu>nt.  ot  tlr-t  .xatmnatmn 
ontainin-  O.imilS  „,!.'.  pT  >  ol.ir  r..ntin..tiT.  a.i.l   in  tbr  la-l   'UM.,!.  nvj. 

|i,T  riiliic  n  iiliiiatrr.  .  .     ,    ,     ,   ■ 

I  n  ,l,i-  ,.x,wn.m4.t  nft.,-  lo-ofu-r  h.M.iMlia.r  .1. .n.tMn  nt  pli.lin  hu 

dcH-rrasiil   to  npio'-iniatolv   nn-fmirth  nf   „l:at    ,t   wa^   i...nni,llv.   "  "  '■ 

at  ,1,0  siHiio  tMi...  tl i.iMnnatinn  ,.f  tlio  ilm.'  in  tlio  lilooil  w,t=  .loublo.l  . 

-o  thnt  with  .ovo„.  am  una  .ho  oMiolin.'  pinvor  nf  tho  kiiloey  wn=  cl.KMTn^eil 

tn  nnc-oiphtli  of  normal. 

rnU-  tho  hi r,no   lio   M'n    ,.,niu..o.   luivvrvor.   l.ttlo  olToot   on   tho 

„,,l„,loin  oxoMtion  uiM  h,.  imtoil.  a.  ran  hr  .cm  from  the  ,.rorr,l,n!r 
protoool  (Tahio  ,S)  ami  from  tho  follnwim:  rt-toml  a^  uoll  a^  fmm 
rlinioal  oMilnu.'  \vhioh  nuI!  ho  pro-onto,!   lator. 

(■„,       WVi^lit.    '2.H    kg.      fn.ler    oMo.i.tone    ane.tlioM,.. 
,.,.,„„    ,„_.i  OP.  4  pfr  eent.  Miiliiini  olilorol   -olntio.i 

;-.:  V :.,  „    rLoi-..,.ho,.,.<...n  -..       :;-..:— 

'"T"::rr:r,7M"r:i:M;n:::  •-  --  ■■••  -  -■-- • 

diiepd  In  il«  plnrc. 


«• 


♦«' 


24 

111.  1-1  r,    111— 111  rr    oi  -!   vvv  umiI.  sniliuni  cliU'ri.l.  ,    . 

;;;.4  :  m-.i  n^.  of  J,l„l,„„.,,l>thaloh,  aa„ii,us,or,.,l.  Dru,  .H— "  •" 
,.o  ninuiu:  „„1  2:   r.r  -vnt.   w...  ..x.ivt.M  in  .ix,>-ix  minutes. 

Thc=c  n-ult^  show  tluu  inod.r.tr  ,l.-nr>  uf  an.inia  il<.  imt  inteilVr.^ 
^vith  the  e.xcrefu.n  of  phU.alwn.  l.ut  that  verv  ^.vciv  ,1..,mv.-  of  an.m.a. 
whuh  Straub  and  Bavcroft  have  shown  to  result  in  the  ei.tuv  ven.ova, 
of  the  tubular  function  of  the  ki.lnev.  nuiterially  .bM'rea^e  tl..'  output  of 
,,l„halein  Tin.  ^voul,l  imluate  that  the  tnbuh-  are  enneerneil  m  the 
exerction  of  ,,hthal.-in  but  at  th.  -a.n..  tin,.  -h„«-  ihat  .1).'  .lon.-iul, 
al?o  are  capable  of  ex.retinir  >onir  of  thi-  dru--. 

„Tin;K   rni:xoMrNv    ni;MMv.;   ox   nii;    MiMuoi.  of   i;xn!i:Tios    of 
sri.iMio.M'.i'iriii  \i.i:iN 
The  fa.  t  that  tl;.  nutput  ..f  phthalein  bears  no  relal.on  to    he  excre- 
tion of  water  and  ehlnrid-  al-n  -n-,M<  that  the  i:lon,eruli  plav  onlv  a 
minor  role  in  its  excretion. 

It  is  .,-,  ricd  \n-  M.lxnidrr-  that  in  ..xpe,  inientally  induced  a^i.te 
tubular  nephritis  (produced  liv  n.rcirv  bi.hlorid  and  bv  potassium 
,,,,„„„te-see  Schlaver  an^  "  ,m.er^' ).  there  i^  a  n,nrkcd  dinm.ution 
i„  „,p  .v.ntinn  of  phthalci-  e  in  the  vascular  tvpe    (p.oduced   hv 

cuntharides  or  arsenic)  little  ..  no  lecreasc  occurs  at  llr-t  but  a  deerea-e 
docs  occur  later-  Thi^  also  su-ests  that  the  ^lon.cndi  plav  a  -ubsuliary 
role  in  the  phthalein  excntioii. 

The  findings  in  our  work  with  diuretics  (discussed  above)  ,,  e..  ,,>a 
those  substances  which  probablv  act  bv  stirnt.latin?  into  activuv  the  renal 
cdk  increase  the  phthalein  output,  ul.le  tbo.-  diuretics  wlmh  act  ou  v 
,„eehanieallv.  as  bv  clu.n,e>  in  blood-pr-Mire  or  ,n  o-„,otu  tensuui  do 
not  influence  the  phtbabin  output.  ,ives  additional  condrniafcn  to  the 
theory  of  activity  on  the  part  of  .1 IN  of  the  tubule-  iu  the  excrCon 

of  phthalein. 

Tin;   STfin    or    \i,i'in:ni^ 

Heretofore  functional  test=  have  not   h,en  ,onMde,ed   o"  ^".v  P^«t 

value  to  the  climrinn  in  relation  to  nephritis.    In  fact  hvpcrpcvmeabd.ty 

to  niethvlene-hlue.  indi.oearnun  and  rosanilin  has  1 n  shown  to  ex.. 

in  ncut,'-  and  in  eluonie  parenchvmatou.  ..ephntn.  xvhile.  on  the  other 

,,„„1    decrea-ed  permeabilitv  with  slow  appearan.e  and  prolonged  excre- 

tion  has  been  demonstrated  in  the  chronic  interstitial  variety. 

a"    McKnidcr:    Ipfcniil   luniiMnniciiticiii. 

33  Schlaver  an-l  H«lin..r:   n.nt.oh.  Arob.  f.  Klin.   .Me.l      IfOT.  xc.   1    an,    xci. 

34  Tl,e  oxoretion  of  thl.  .Ir,..  in  ..x,...rin,on.«l  n.plni.iile.  i.  now  nn.l.r  study. 
..,.'.'  For  lifcrnlur.  c-oncernhm  "tl.-r   functional  WU   «-.  -ur  original   urt.ele. 

.Tmir.  n.arm.  and  Kxp.-r.  Thcrnp..  lOH'.  1.  S''-'- 


25 


ACUTE    NEPHRITIS 

Thu.  far  .c  l.ave  ha.l  .pportunity  to  ^tu.ly  onlv  live  ca.o.  of  a.ute 

and  .Lowed  evid.nco  of  ,r.ve  <"-'"»■' \;^,;3ita      An  injecUnn  of  6  mg. 
the  toxemia  wus  due  to  the  nepl.nt  s  or  to  t' « J>".'  »  J  j^ 

of   the  phthalein   «o.   f.dlowod  by  ^'' V'/,i;T"' ?     he   d     "   wal   excreted    in   the 

r'^::r^;^:r^:^ien^^;r:d^:nd^:h:  :;,::;:>.  .;;.,ete,.  ...>.  >. .« 

at    the  time   of   the   lir>t   t.-t.      in-    i  .'      „  ,  ,„,„vri-t^      Tlie  tuojinosH 

,„,oky  from  blood  and  contai.unf:  .nuoh  Mbumu,  and  nu.nN  ca>t. .     1    e  ,      . 

'"'t?'  ^"'•,,  „|,tl,.>le„>  le.t   wa.  adnnni-t.red.  the  .Irug  appearing  in  the  urine 
Ihe  uMial  phtliakin  u.i   \  a  i-xcreted    in    one    hour, 

in  twenty-two  minute,  and  only  /•^ '•^. '''';,  ^  ,"-,,,„,  „„,,  ,he  elinical 
Three  weeks  later,  the  nephrU.s  '--l^^,,"  ^^^  ,/^;^X  on  ..f  tl.<  -ine.  the 
oondUion  '^-'^,^'-|>;^.  ■;:?•;;::  „;;^'.  ^^  'he  dmg  m  .even  ,ninut..  and 
,e-t  -»V';i'7^";;:'  ;,"^,„"'f,  '!,ne  hour.  Six  week>  later  the  pafent  was 
an  exeret.on  of   .,S.l    1' y    "  .       .,„  „,^    ,|„se  in  the  first  hour, 

entirely  well  an     -"-;■':';';•„,,;.,.  „f  .„„,„„.  ...nire  assoe.ated  w,,h 
r.\sE  3.-.\  boy  of    ,    .\ea.~  lad  •>   "        "  ;         ^,,   „,,,,p,„.ance  of   the 

purpura  heinorrha.iea  -'V';:;  "^  ,  '  "  "  exeil  d  1M.4  per  lent,  in  the  first 
r"""""";   :::  r:  :';";:;         el:,    1';:      neatl,  ooeurrea  .udden,y  tive  days 

severe  gra.le.  the  prognosis  being  -"-de,  .1  •'"'  '  "^  ' ;  ,^^./^,,^  ,,,„(,„,  eon- 
en  .imission  «;v/,  r*;::;!;/';!  ::;e  ;tp.n  ;::dtu^-ed  to  .s.4  per  oent^ 

-r^r^:'r■^--:'.  ■-;:-;:;:  ^:r^r';^     •-" • 

,„e  l'''«''"'-"p-'7";"7'-:;,'      '':;.,       „nl  a   fe.   ...U-  before  adn,.- 

.  .VSK,  5-1  he  patont.  ■'/^       '^  ;,     •',,^        ,,    ,„,    ,„a,ked    edema.      Marked 

M„n     I  May.    i:ilt»i.    when    '''    ,'''^' ''''^    .,''.,■      i,,,-,,,.  aneamt  of  albumin  and 

^' \ ; ;r'::;;";t;!:: ;;;::;. ;::::. i.  niere  we,.  „-. 

l;,rp.    „u,>dK.r   of    ..-ts    "'!"•'  subeutaneoii«lv.  showed   211   p.T  eent. 

-:„:";:;;";..;;:.■:''""'■--"'"-•«;' -• .— "■• 

'-"^:  ;;:;:„r:l->-ii;M ":::-" :::«:'  .:;'-•• « - ' 

nephritis. 

NVl.kMio  ooiul.MoMs  >an  l,e  ,l.iu,,  tnim  l;^lMases.  i,  is  .......stivo  that 

„,  „„„„  ,.f  „,„„  „,.  n>e,o  imroasoa  pernu-abilitv.  hut  that  .in  thn  oin- 

,.,.  the  por,n..ah.l,.v   was  n.arke.llv  .hn.n.sod  .hon  the  con.lit,,.,,  wa- 

:.,,,J,H„.anv,ravo.      Ins,,,,,,.    .,f    „...    .a-,,    holow.   .lassod    as 

,.,1,,.  ..phr,,,-.  a„  aottte  «a.ori,ati,.,,  .as  ass,,.at,.l  .ith  th.  cluon. 

n^p,,n,isa',hot,n.,.of.h..t,.-t.     Hor,.  aKo  tho  p-u.h    ,tv  w:.  ,Weaso,l 

b„    w,n,th,-s„l,si,le,..,o.,fth,.a,„.,.p. ^-s  „H.  pon,.,.ih,h..v  ,t,..roase,l. 

,,,„„,.,    ,„.    ,„„„„„!„.r,.,l.   l„,wov,.r.   that    Nvhon   an    a.ut,-   process   ,s 
p,.e«.nt.  va„at,„n~  n,  UunU^u  ,„:.  ho  v,  ,v  rnpul  an,l  that  a  .ood  cl.,m- 


«• 


2C 

natii>n  un  mir  (iav  iiuiv  lie  I'olloucil  within  a  ilav  ar  two  hy  a  niarki-il 
iU'c-ri>a-e  in  ruiicti'Hi  ami  rirr  i-i'rsa.  CiuiM'iiiirntly.  in  rasts  of  tin-  tvjn' 
tlie  ti'!-i  yliiaiM  lie  rcpratcil  l'ri'i|H('ritly. 

CltliONH       I'AKINt  IIVMAIOI  .>^     M;1'1  1 11  lllS- 

In  all.  tweiitv-livr  cases  liehin.L'ini:  to  the  -o-called  type  of  paivnehy- 
iiiatuii-    n.-iihritir.   Ikim    been   >tii(lie(l.      Tlie-c   (ases    represent   ilifTerent 


a 


TABLE    7.— rARKNi'UVMATOUS    NKriilUTlS 


flinir:il   » "ntiiiiiiuii 


S.  G. 


Albumin. 


1— u. 
•J     u 

rj  '  C.    n'.i 
)L>   111  ll'.l 
IL'    11    ll'.l 

r.'  1:;  ll'.l 
r.'  J4  111 
!■-■  i;'.i  HI 

n  -I! 

4  — \V 

1. 

1...  iiL-.ci  :;2. 

-     1  /HI 

1  js,  10 

.-.    M 

.  UCIil  "1.  . . 

;i  • .-) ,  ii> 

i— .1.' 
11     1' 

■•laid  :'.4 . . . 

ilKc  (i  ".'.,.  .  . 
.1..  niz-''\  :'.ii. 
S  .  a  1:1  (1  Iir). 

.•1  1.-  Ill 

L'      1      111 

4     4     111 

11/  T  ,  III 

Some  cdi'nia  nnil  nni'inia. 
KJinui  anil  lullil  anomiu. 


lii'tlir  .  liiileallv    

H..|t.'i-  c-llnl.-ally    

Svin|ifnni<  uvi>  innnllis  ;  mild. 
Fair  .■unUltlun   


Vory    mild    s\  mpt'ini^i  ;    n Ii'iiia  ;    slialil 

aiii-niia. 
Had  ;   mild   uriTiila   pn  vioiis  to  ndmisslon. 

Fair   

Fdi'nia.   alit'lnia    

I-Idi-nia,  aiu'iiiia    


Ill 
l.-l 


r 


.111 

:    oil 
i  "■• 

.".1:: 

iM      MA.   aC'd 

1  1      I\        '..'., 
IJ      ,1     S  ,    air.'d   r 
7,-..->.si 

r;     K 

14     r  ,  n2Pd  .'tn. . 


1.-— S..  ngi-d  i'H. 
1' .  11:;.  d  : 


II    r.    Ill 


II 


17— v..  nu.'d  48. 
10— n,,  n?.d  'J«. 


L'u-  I-;.  W  .  aL-(.l 


11  14  111 

11  i;  1  111 

11  ;;ii  111 

11  -ja  HI 


21 -r. 


nard  40. 

7774.-1 
22— E.  D.  nerd  10. 

774L':i 
2n— AB<d  2."5 

24— Asi-d  :ai 


Jli  HI 
12/111  10 
12  211  HI 
l/:!,ll 
1  II  11 
1  17  n 
2 '  7  / 1 1 
1  I'.-.  11 

4  11  11 

■J    M    11 

4  :j'.i  n 


;!/ HI/11 

77     HI 

:!  I'll  11 
:;  .'s  11 

4   Ulll 
4   2.V11 


IMi'iiiK,  tlyspnia 

.\|i|iar..rillv    liiiiin.vi'il  olinli'nlly 

Sliuhl  •■ilrtiiii  al  lliiiis;  no  uIIut  symptoms. 

IMi  ma.  dvspii,.a 

fr.  ml,'     

i:doiua  :  slitlit   

Kd»-ma.  aiu-mla    


fJlvTO  <i.4.">  salvarsan   12   l.'i    10 

Cllniia!  .iiiidlliiin  ixoiMllnaly  grnvc 

No  rhnni:«> 

Miiih   bittir  

Much   iH'ttcr 

No  ►vmptnms;  nl'pll^ltl^  iliti'rti'il  nooidi'tit- 

alty. 

Iniiav. nous   Inji'i'tion  

MM. I  cavr    

I.jilior  Ind 1  llvi'  davs  pn'vlims  to  list  on 

nnomit    or'    thrrati'iifd    I'llampsla ;    fair 

nitnllllon. 
Illuli   btood   trnslon.   aiiiTiila.   siiuu-   I'llt-nia. 

rri'inia  :  naii^.  a  and  vomitini; 

Kdi'ina.  dys|ini  a  :  rllnlcally  Kiavo 

.Ml  ait  Kann'  rondliloii 


;iii.- 

•_'(;:; 


No  symptoms  . .  . 
I.umliar  InJiTllon 


4/18/11    I    Kdomn  :  anuria  for  four  days  t)i  fori'  adml« 
I        slon. 
niicknrlii' :  no  otIiiT  symptoms 


.%2S/1I 
5/  »  ,'11 

.'i/e/n 


Anitp    nophrltls     om'     yonr ;     no    od.ina ; 

t»tood-pri'SKMri'  00  mm.  Ilic 
Tub'Tiulou^    nrllirllls;    no    illiilial    svnip- 

toms  of  pi-philtjs 


1:14 

17" 
L'L'l! 
1111; 
112 

1 2r, 
2:!ii 
72.1 


:'.74 

I1111 

l.-ii 

70 

73 


0.1 
200 
400 


1.012 
l.O.-fO 


1.(117 
1.010 

1.005 

i.oi;t 
i!6(i7 

1.011 


.»<l! 

l.Olfl 

Sit 

1.000 

■M 

1.012 

Hi 

1  .iiad 

t;s 

i.(i;i(i 

1  ( 

l.oiio 

1.0K! 

1.017 
1.1118 
1.024 
1.(122 

1.02fl 
1.010 


1.008 


1 .02(1 
1.018 


1.014 


1.019 
I.OI.-1 


+  + 


+  + 
+ 

+  + 
+  + 


00  G    alb 
00  G.  alb. 

+  +  T- 


+ 
Alb   0  r, 
to  liter. 


-4-  + 
+  + 


+ 
+ 


+  ■*- 

+ 


B  n.  la 
llfi-r 


»7 

frradt".-:  of  i-evcrity  and  tin-  duration  of  the  disease  variw  from  a  few  week? 
to  seven  year?.     Detail?  conceniinjr  tlie>o  eases  are  seen  in  Table  T. 

In  five  verv  mikl  case-;  of  short  duration  showing  only  slielit  edema, 
with  albumin  and  easts,  but  with  a  norma!  urinary  output,  the  time  of 
appearance  cf  the  drui:  an'  the  amount  e.xcreted  was  normal.  In  one  of 
tlipsp  (ii^cs  (Xo.  ■"),  'I'ablr  .  I  the  time  of  appearance  was  eidit  minutes 
and  tlie  output   ',2.r>  prr  c'-ut.   for  .me  hour.     Another  patient   (  N'o.  1"A 


■lAi'.i.i: 


I'AIIllNrilVMATliIS    NDI'IIKITIS 


I 


Mirro<roplcal 
I'iiiilin:;- 


PerConl.  of  nru!! 

KxLTi'tt'd  in 


Onp 
Hour. 


Two 
Hours 


K'lnarks. 


Numerous  casts. 

Oasts. 

Casts. 

Casts. 

Casts. 

Casts. 

Casts. 

NunitM-otis  casts. 

R    B.  C. 

Casts. 


l\'w  I'asts. 
Casts. 

Ft^w  casts. 

Casts. 
Casts. 
Casts. 
Casts. 
Casts, 
Casts, 
casts. 
Casts, 
Casts. 
Casts, 
I  asts 
F»'w  casts, 

K'^w  casts, 
Kiw  casts. 
MaMV  casts. 


Ca-ts  ;  few. 

Casts. 

Niimcr'Mis  casts. 

.Nuiuerous  casts. 

I'on-  casts. 
Ki'-.v  casts. 


NulucroTls  casts. 
Few  casts. 
Many  casts. 
Some  casts. 


H.2 

14.1) 

:;."i,ci 

■2H.S 


ITeters  latlieterlred  and  oriual  amounts  from  encti  slile, 
Impossllile  lc>  in.i.M-e  uriii:Hy  secretion  l-.v   furiili^'  water. 


2:1. S 


4'.'L' 
4(14 

tt,*.i 

Tra(e. 

411.4 

IS.'t 

2(1.4 


;!:t,n 

47,(1 

.•;:!.;! 

r.i  (1 

.'il.O 

L"i.0 

'».'i  7 

4^.1 

ri.'i.ii 

Cl.tl 

Suhcut. 

54.4 

•47,0 

.-,1.0 

2.0 

Illl.O 

l4:i     I     24. :t 

No  ilruK  In  4  hrs 

(i.l)     1      .... 

....     I    in.6 

I 

Subeut 

ln.l. 

.-.1.(1     I     .... 
30.6 

60.0 

06.8 

r.7.8 


r.4.ft 

:t2..i 


Ii|e(1  of  uremia  two  moiiili-i  hiicr. 
CIven  :i(l  niK-.  but  output  not  estlmalid. 


Iile.t    11    IC.  Ill,      Autopsy:    sev.  re  ainylolrl    neplirltls.   s.TpliilitIc :   sen- 
erui  iiniyloidosN, 

Re.v.v,  re.l ;    vporl-    l.erself   feclln-'    well    at    pr.  sent    i'^oe|U    for   .denia 
l,\pril  1.  I'.iU  I, 

Left  hospllal  In  fair  eoiiiUlion.  hut  allinrjln   1 C.  L'ni,  per  lllerl  ami  easts 
were  still  present. 


The  exi-reilon   for   llr,-l    lialf  hour  after   luliaveioius  ln.|eellon   Is  liehnv 
normal. 


Svniptoms  for  six  years,  onlv  in  winter. 

liliMl  iw.i  (lavs  later  lu  uremia.     Xo  iiulop-y. 

Iieveloneil    ervslpi-las    and    followlnu    lids    nn    emiivema.    whleli    wa« 

drained.      Died    41(1  11.  Autops.v  :     Ijirne    white   kldiie.vs;    subacute 

peritonitis. 
Albumin  and  casts  dlscov,  red  ac.  lUentally. 


Volrted    freely    after    admission  ;    edetna    disappeared    lu    a    tew    days. 

iJfl'^linspft'al   In   a   few   days:   felt   perfectly   well:   albumin   and  casta 

still   tiresent.  _,  , 

Clinically  Ibis  case  Is  considered  ti  have  a  Kood  prognosis. 

No  symiitoms   of  ni  phrlils  ;  olbumln   and   casts  discovered  on   routlnn 
eiamlnatlon. 


•  Ila!i-huur  ti  «t 


28 

■n-a?  a  studont  wlio  considered  liiiustlf  piTl'citlv  well  Imt  in  \vlio?o  urine 
albumin  and  caft.-  were  discovered  liy  clianee.  On  close  inspection  a 
slight  edema  about  the  eyes  was  detected.  No  other  evidence  or  sn^';:cstion 
of  the  disease  coidd  be  found.  In  this  instance  03  per  cent,  for  the  first 
hour  and  ^.0  per  cent,  for  the  second  liour  was  excreted  followini:  subcu- 
taneous injection.  After  intravenous  injection  -SO  per  (cnt.  wa-  excreted 
for  the  first  half  hour  (sli.-rlitly  decreased)  and  IT  per  cent,  for  the 
following  hour  and  a  half.  In  three  other  ca=e:^  a  normal  excretion  was 
found  but  all  three  patients  were  free  from  symptoms,  alhuniin  and  casts 
lieing  the  only  indication  of  disease. 

In  cases  of  longer  standing  or  cases  in  which  the  disease  is  rf  ordinary 
^■veritv  the  tinu-  of  appearance  has  alwa\s  been  delayed  slightlv  ( t  mm  ten 
to  twentv-five  minutes)  and  the  amount  e.xcreted  is  definitely  below 
normal. 

Tnlilo   7)    who   lias   bepn   under   constant   ot)-(>rv;ition 
(twenty  minutes)   ami  tlii>  aniiinnt 


In   KV-v    [latieiil     i  No 

for  ni(ir.-  tliaii  a  \.Mr  I'nr  time  of  appearance    .-    

pxcreted  for  one  I'lonr    riO  \ht  cent.)    lias  r.Miiaine.l   [iract  ically  tiiulian-ed.      ( 
ically  liis  condition    i--  liottcr  than  a    \car  a 

Anotii'  r    j'atii'iit     i  N 
.Vi  V.   ii."i.    llilo.   will 


admitted 


11.     lal.le    7 — If    .il-o    (  liart    1.3).    age    .'iO. 

IIS   and    a    d.lliute  parcncliymatous   nephritis  of 

at   which 


\,,V     ■',)       IMIO      WntI    -li'MMiMM      llU's    .iii'i     .1    ii'UMii^    |.„, .  ..^  .,^. ...... ... , 

six  months-  .Inration  s1h,h.,I  an  .mtpnt  of  .)7  p-r  cent,  for  two  hours  at  which 
time  his  urine  contained  oO  -m.  alliumin  to  tlic  liter.  December  l(t  In-  phthahm 
nntpiit  uas  -,1  p.r  eeiit.  and  the  allmmin  -'J  fini.  to  the  liter,  while  his  j;er.eral 
condilioii  showed  hut  little  chaii-e.  Ih'causc  of  the  po-sihility  of  the  nephritis 
l,ein.'  svphilitie  in  ori-in  0,4.-.  j.'"'-  of  salvarsan  was  f;iven  intravennusly.  Decem- 
tier  id."  his  condition  was  ijelhiitely  wiuse.  urine  decreased  in  annmnt  ami  tiie 
.1,...".:'      :..-.,„... ,.,1    ,.,    e.s    ..,„     tn    the   liter,   the   idithahiu   output    dropped   to   31 


aUiumin    increased    to    I'.s    i;ni.    to    the   liter,   tl 

per  cent,     .laniiaiy    3.   hi-   clinical  condilinr.   \va 

the  liter  and  tin'  plithalein  excreti"ii  was  -22.7  per  cent. 

was   the    -ame   and    Ihe    idithalcin   output    iinclian^ed.      (hi   .lauuarv 

his    clinical    condition    was    imprevcd.    alhumiii    ilecreased    in    anmunt 

''  '  7.   tli(>   eatient    ua 


phthaleiu   output    droppe 

i  vi'ry  prave,  albumin  '.Mi  f:iii.  to 

damiary  H.  his  condition 

17.    however. 

1    the 
a  ;.'a  i  n 


phtlialein   output   increased   to  43   per  (. ,-     .-  , 

in  L'ood  clinical  cenditiim.  the  albumin  only  li  (.'in.  to  the  liter,  while  the  output 


nt.      l',-liniaiy    7.   the  ] 

^ IT. 

cent.     The  blood  pressure  throughout   range 


of   phthalein    increascl   to  .>-..    ii.'r   eein.      roe  ..,..>..,  |.,,  ...... ^..  .■■ - 

from  SO  to  nil  ami  no  cvechang.s  were  present.  .Mlhouu'li  the  phthnlein  nutinit 
droiiped  ftii  ;e,,««  with  the  evaciTbation  of  the  clinical  manifestations,  yet  at 
no  pcdnt  dill  it  reach  a  level  which  wcmld  indi.'ale  an  immediate  danger,  whereas, 
1      .1 :.i I    :....>i ;  it.Kt 


clinical!} 

.\nedliei-   illtercsliii 


h  was  (•<.nsidered   imniineiil. 

(Xo.  r?.  Table  T)   is  as  follows: 


with   tlie  pxcepti"ii 
had  disiippeared. 

In    the   most   severe   L'radcs   of  chnniic   |iarcn(  hvmatoiis   nepliritis   or 
wbirc   the   di^ia^e    is   of   loot:   slandinL'   and    a-^o,  lateii    with    s,,ondarv 


29 

stlorutic  cliangw,  tlio  outi.ut  is  reduce,!  \ery  iiiurkeclly,  and  in  some 
instances  no  trace  of  the  drug  can  liu  found  in  the  urine.  Here  also,  as 
in  the  interstitial  type,  the  absolute  failure  of  excretion,  or  the  excretion 
of  a  mere  trace,  has  bc-en  followed  within  a  -hort  time  by  death  from  renal 
failure.     Some  details  rejiardin.LT  a  few  of  these  cases  may  be  of  interest. 

F.'irale.  n-'cl  'is,  adniittr.l  in  Ai.-u-t.  lIMd  (Ca-e  18.  Table  7).  History  of 
edema  of  faee  for  ov.t  two  v.^ars,  SnIlViT.l  some  Iio.i.  lieadache.  For  a  few 
months  t,.eviniig  to  admission  had  Urn  u.iahle  to  work  on  account  of  t:emTal 
weakness.  On  admission  had  nausea  and  occasional  vomitin-.  Mentally  clear. 
Marke.l  anemia.  Some  e.lema  of  face.  Vrine  c.mtained  larj-e  amount  ot  alhnn.in 
and  numerous  casts.  Outlet  of  urine  small.  I'hthalein  test  piven  an.l  no  trace 
of  dru"  could  be  detected  in  the  urine  durinf:  tlie  next  tlnve  hours.  She  ^Mndu 
allv  hocnme  more  uremic,  the  nausea  and  vomitin-  becomin-  rather  cont.nu.,us 
althout;)!    mentally    clear.      Death    octiu  red    within    f-mr    (lays.      Xo   aulop-y    was 

obtained.  .  .  .         . 

Another  case  (No.  10.  Talde  7 1,  one  of  .-.yidnlitic  n.  idiritis.  was  (,t  latl.ei 
peculiar  interest.  -M.  A.,  afied  23.  admitted  Oct.  24,  ItlKI.  exhihitm-  severe 
Treneral  anasarca  and  marked  dyspnea.  Symptoms  bad  existed  for  one  month. 
Pulse  small  and  of  low  f  nsion.  Some  anemia.  No  sifius  of  uremia.  Heart  was 
normal.  The  urine  had  (i  -m.  of  albumin  to  the  liter  but  no  casts  were  l.iiun  . 
Tr'.ce  ni  sii„ar.  Some  davs  after  admission  hyaline  easts  were  discover^. 
November  S.'the  albumin  liad  increased  to  30  f;m.  t.>  the  liter,  although  the 
dvspnea  was  better  and  the  peneral  e.Uma  somewhat  decreased.  Ihe  phthalein 
output  was  at  this  time  only  (i  per  cent,  for  two  hours.  November  14,  the  f;en_ 
eral  condition  seeme.l  about  the  same,  but  her  phthalein  output  ba.l  decrea.^ed 
to  a  mere  trace,  The  following'  day  she  became  suddenly  irrational  and  rapidly 
went  into  coma  and  <lied  within  twenty-fnur  hours.  Autopsy  lindin-s:  syphilitic 
hepatitis,  creneral  amyb.idosis.  especially  of  kidneys  and  spleen,  thromlKisis  of 
ri{.'lil  renal  veins  and  veins  of  left   side  of  pelvis. 

Althou<;h  the  number  of  cases  of  chronic  parenchymatous  nephritis 
has  not  bee'n  very  larpe,  sufficient  data  hiive  been  collected  to  indicate  that 
the  test  is  of  decided  value  in  revealin-  the  functional  elliiiencv  of  toe 
kidnev  in  this  condition.  In  the  mild  cases  very  little  disturbance  of 
fumtion  is  indicated,  and  it  niav  be  impossil.le  from  the  test  alone  to 
dillerentiate  this  (onditioii  from  aliniminuria  iinasscuiated  with  coarse 
renal  lesions.  When  there  is  a  marked  .lecivase  in  the  phthalein  output 
ir.arked  renal  chan.^'es  are  present,  and  when  only  e^eiaed  in  traces,  or 
not  at  all.  a  L-rave  ]iro<inosis  should  be  piven  evi'U  thoiurl,   ,,0  sil'us  .if 

uremia  exist. 

cimoN-ir    iNTi;i!sTiTi.\i,    NicriiniTis 

Twenty-three  cases  of  the  type  clinically  classed  as  chronic  interstitial 
ncjihritis  have  been  under  observation  (see  Table  R).  In  manv  of  these 
cases  previous  to  the  adminisfrati.m  of  the  phthalein  test  ro  accurate 
idea  of  the  decree  of  involvement  of  the  renal  fiUK  tion  could  he  ascer- 
tained even  after  the  most  careful  cliniial  studv.  The  phthalein  test 
has  proved  itself  of  immense  value  in  r,  vealin-:  the  de-re"  of  destruction 
of  the  renal  s-.ibstanee,  and  has  ,1,  ,„oii-trated  it^df  to  be  of  extreme 
importance  fmni  the  standpoint  of  both  dia,t;i,"sis  and  proc;nosis. 


#• 


TAIII.E    S-      CHHIlNlC 


Dat.' 


clinliMl  Ciinilition 


S_     .5 

^—       o   . 

c  -_  -^ 


S.  G. 


Albiimiu. 


I  -M 

I'-F.    S.   ilK.'ii  71. 

;!— M  .  :is.d  4S.  .  . 

4—1!..  aii'd  .-.-,.  .. 
.'i — S.,  aj:eil  "iii.  .  . 
li  -1.    I...   llCi'.l  .'!'. 

7— Mrl'..  aL-'il  I',,"., 
.s  — It..  au''il  .'.1.  •  . 

II  -«'..  ivznX  "■'.'.  .  . 
Ill  -11..  iiLMcl  .-,.-,.  .  . 
II— K..   Bi.'1'd   -43..  . 

7.".  till 
li:-Mr<.    W  .    au'.il 
■n.     7:.T1- 

i:;-  F.  i;  .  !i--.m  71. 

7."741 


I  1-  II..  .ai."  il  I'.."  .  .  . 

7r,'.i4:i 
ir,  -M,  M,.  M-.d  :;- 

Id— .T.   H.   S..   need 

till.    7r.!vts 

17      A.  T..  lIL-d  r,!t. 
7i-,l"'i 

IS     II   i;  .:!.:•  i!  :'.i;. 
7i;4!ii; 


m— Dr.  II..  acid  41 
'^\ — r..  ac^'d  .J*-.  .  . 
SI —I..    M.    T..  MKcd 

fill 
■.■L'        II      I..    II  .    Il--d 

IT       774  f.l 
u:;      \V.    r  ._:i.:'d    40 

L'4       I..   I ; '. 'i7-'.-.I    11' 


'.'.-.      S     li.    II  .    ilil'd 

SlM-L-.    \". 
■J  .-.171 
•jr,  -  I.,  aci'd  50. . . 


I> ,  !ii;.'d  70. . . 

1-.     il-rd    .-V.  .  . 
Ill-     S  .  M.;..!  4n 


.'ill — r..    il:: 


:;i       \V.    1!  ,   ;li:.  d   .-II 

77:.'iiii 
:'.!'  — II..  aged  5(3.. . 


W.-V 

;!4— T>r.  (i. 


ii;  ij  ii;i  i    

-  '  1     111    I    Arf-riost'lrrusW.    mild    (\slitis;     fair    <on- 

ililli.n. 
1   JT.  Ill   I    ArtiM-liisi  liTci^N.      Iiyiirrtriiphy      of     lifart, 

U'-'ll(/IO   I     

1   Jil,  111   I   .XrterlosiliTDsN    

;;    N    10   j   (ioiid  londltion    

:;  i:;  111  ■  

1   us  111  I  Tvplioid  ;  :Jd  nlapsc  ;  :id  inontli  vt  disiasi'. 

:i  :!1    111  i  ciii.d   .  oiidillnn    

1    l.i   In  j  Mild  mpluitis;   g 1   condllion 

11    7  ,  lu  I  ,\rtcriu>clirusis  ;    liiu-ii    bliiod-pressun'.   Tlo 

'        nun.  Hu'. 

11    !i,lii  I'ri'niia  ;   lii.'li   ;;radi'   (hck'd  disc;  ani'iiila 

SCVtTl'. 

II     1,1    111       Arti'l-loscliTosI--.       n^t   o-arthrills  ;       bloiid- 
l-rr.sMire  iiJti-li'J.i  niiii.   II:; 

II   :.'i    III       Art.Tinsi-l.Tusis  ;      l.lunilpr.'-Min'      I'lO -JUil 

mill.  11::. 
U   Uli   III    :    N;iiis.-u,    lieadai  !i.\   aiit'inia  ;    blnodpi-fssiiri' 

L'l.-.  mm.  H::. 

r_*    ;!    In    :    rniiditi'in  wm  <•' 

lL".'i    lo   1   fenhrHl  art.'ilii^i'li'i-nsls  ;    altai-ki  .if  iiiRon- 

sci..ilMi.ss  :   bl.i.irl-iin'ssiif..    l.SII-Vllll. 
rj  i:i  10   I    Kdema.  dyspnea;  bl.j.i.l-pf.ssnr.'   Iilil-lMi.. 

1     7    li  j  NauM'a     and     li.'rida.li.'.     Iivpi.lliyi-i.i.lism  ; 
l>l,,...l.pi'.>..<iir.-  Il.i-l;;.-.. 

l./il./ll  1     

1/I!1.10  I     

l.'L'T.'IO  '      

li;  .'U    111  !    Nil  sympl.ims 

1  L'li,  111       No  svnipi..iii'<   

■_'    7/11  I  .Nans. a.  beadacli.- ;  visual  distiu-bancs.  .  . 

:;  _'|   11       '  ;iil<..l     anemia,     inr.i-oa ;     bl....d  pr.'ssur.- 

i;;i. ;  n.i  ...l.iiia. 
:;  L'4   II    '   Tiilii  T.iili.sis,  osiioiinelliis  ;  p.Tslst.ait  bii-- 

I       i-oni:li. 
:i  :;s  II    I    DincnosiMl  on  artmlssi..n.  dlab.'ti's  insipid. is  ; 
sllibt      Kl-ad..      ait.'rlosil.Tusls ;      l.lo.id- 
I       pr.vssure  80-00  mm.  Mb. 

IL'  j7  <i;i   '  Slight    iipailai-iii-.    morning    naii-i>a :    men- 

1  lallv  cl.'ar  ;  bypiitr.ipby  of  piostat.'. 

1  '7    10   I     .....' 

1    1"  111       Injection  SO  mg.  philial.'ln .... 

4  2Tt  II    I  Na.isi'u.   viimitlng;   bl.i.idpresui.'   lOn  mm. 

1  III.-. 

4  11   II    '  r.'i'.'brai   ari.M'losrIorosls.   mym-anlitls.  cm- 
plivs.'ina  :  bliind-pri'ssure  liin-l'l.-)  mm.  Ilg. 

.-,7     II        I!a.| '.■llni.al   .■.indltl.in 

1  I'l   II    '  Iiv^t"i"a.     nrtiTloscl.'i.isis :     blo.i.lpr.ssin-i. 

I  'l7l!Ullll, 

4  111  II  Maik.d  r.'r.'bval  nrt.rlos.l.Ti.sis  ;  blood- 
I        pri's.suie  lino  mm.  Ilg. 

4  L'l  II  I  .\rt(M'lo«i-Ii'rosls  and  byi).'rt.'n«l.in :  blood- 
I  prcssim-  170;  attacks  of  nncnscioiis. 
I       ncss  ;  drowsy  and  oncoming  nr.'mlii  sus- 

I led. 

;:  .';o   ll    '    .\rti'rliis.'li.rosis.     n-r.'brnl    nrtorioscl'-rosls, 

.hr..nl.'    n.'pbrlils;    blood  prcssufi'    1S5- 

12411  mm.  II'j. 

4  '.ill  11    !    .Marked  I'vc-.iiangcs.  partially  blind  ;    blood- 

!       pn'ssuiv  liiii  mm.   Ilg;  no  cdi'ina  ;  good 

plivslcal  coniiiii.m. 

.-'1,11    I   .Vrtcrlosolorosls,   bypcrtonslon  ;  good   pliys- 

I        leal  condition. 
5'1    It       No  svmpioms  ..xc.pl  bvpcrncldlty,  gastric  ; 
tr.nc  r.r  ::lb-.:m!n  and  few  casts  f'jr  ten 
years. 


1.-. 

i:!4 

ir> 
i:i 
ij 

4.-1 

IJO 

02 

•  • 

0 

s 

.-.(Vl 

y.vi 

470 

i:ti; 

4S 

loi; 


i:iii 
:;4 

1114 

4S 

127 

lln 
70 
1711 
lOo 
L'lO 

lull 
l.-|0 

:;4o 


1.051' 

1..117 

i.iii'o 
i.ui;:t 
i,u-J4 

1,023 
1.000 
1.O08 
l.OUti 

1,011 
1.015 


Alh,  I-.-.  G. 
to   1.. 
Trac... 

Trao.'. 


TraDsi.'Qt 

+ 


I   Trace  ,if 
nlbumin 
I    found  a 
f.'W    rimes. 


l,iii;i 
1.008 
1.014 

i,oi;2 

1.020 

l.llll' 

1 
i.iiiin  I 
i.iiiii  i 
1.0117 


1,1108 


+  - 

Tr.lMV 
Trace. 


-f 
Trac. 


1.015 
1.00." 


i: 


i.iiiir. 
l.ou' 


40        ...    .    1.011'    !      Tra. 

!              i  I 

?.n  j    ...       '     Tra.- 

;    ii'O   '    i,Oi;i)   i     Trac 

I 

.     !   i::.-.  I  l.iVJd 


\ 


I  :;i!o  \  1.01(1 

I  52  I  1.020 

I  I 

I  24"  1,010 


4.->  1    1,02(1 


+  + 


TriU'o 

on  oil'* 

oceasi.m. 


Tra.' 


IMLUsliriAL    NKI'IIKITIS 


l"mdin;:s 


PfTcontagp  of    I 


OOP 

Hour. 


Two 

Ilom-i 


UfUiark^ 


llvaK  and  gran. 

,asts. 

N,!ni*'rnus   hynl. 

anil  L;ran.  casts. 

No  casts. 

Casts. 

('■ran.  and  byal. 

casts. 

i.'asts. 

0.'cas.  casts. 

Nil  casts. 

Ni)  casts. 

I'.'w  casts. 

No  casts. 

No  casts. 


Ilya..  and  gran. 

<asls. 

lew  casts. 

r.'iv  casts. 
I'ew  casts. 

Nwnicroiis  casts. 

I'.uv  casts. 

r.-,v  lasts. 


c  a-is. 

t'asts. 

N'tiniiTous  casts. 

\.>  casts  ;  few 
If.  B.  C. 

Casts. 


-'(i.."i 
:!.ii 


Nu  casts. 


Nrj  casts. 
0 


N->  casts. 
( 'asts. 


casts. 

Casts. 

NiHucrous  casts 


I'rw  casts. 

lew  casts. 

Casts. 

N,>  casts. 
(1. -asi'iral    casts 


0.0 


■4S.;', 
411.:: 


4".  .I 


ti.ll 

0,0 

ir,.o 

■.\:\A 
n  li 

.T.S 

;i4.7 

2(1.  S 

no 
e.n 

4.1) 

M.O 
40  <> 

:;^ ." 
11.11 

(l.fl       i  0(1 


:xcM.-.l  al.oul   1   i-r  crrit    fur  on..  hn;ir  :  .li-l  In  iiivmic  convulsions  two 
w,',U^  lal.  (■  ;  no  aulo|)sy. 


0|t,(l 

IS..'-. 


I         0.0 


1       ;'..!» 

I    Tra.c. 


2.0 


Trace. 

Trace. 

0.11 

\:,-2:< 

r.'..' 
;is.i 


I     4n.o 

17.0 

s.o 
soo 

51.0 


lii,.,l  t«..  ni.indi-  lal.'t:  n..  aiilopsy  ;  syniiil..nis  chcnic  ur..mia. 

Died   II   14  1".     .\ut.ipsy:    Small  sranular  kidneys  with  superimposed 

acuic  h.  ni.irrliasic  neiitiriiis.  ,.,,ci..     itmi.hv  of 

Iii.ii    n.l.-,  Ill     of    liron.!i.ilin..(inionlM.      Autopsy    l.!4lill        •>"'^,''",>    "' 

rlL-tit  kidn.'v'fruo    ,kl  r.nlil  thro,„b..sls  ;  left,  small,  granular  kidney. 


|.,,|„,rt   4    111:    In  liad  condition  ;  unable  to  s.'t  about  ;  vomiting',  b.ad 
acli...  el. 


ITlsehar-.d  ill  7  11.  fclln-  b.it.r:  li..ada.  lies  and  nausea  s.une  better. 


]    Iii..d.  ur.iuia.  4    17   11;  no  autopsy, 

l!.',-anie  .in.wsy.  :;  -7   11  ;  di.'d.  ur.'mia.  4   1   11  :  nephritis  lo.t  susp.'.ted 

lilc.Tof'l'i^b.Tculous  i.neuue.nia;  moderat.'  trade  of  chronic  n.^phritls. 

Tra...  .,f  albumin  found  before  admission;  about  4  0  n.  he.idache  and 

l,„, f  albumin   and   few   casts  in   urine;  .i.ert     in  uremia.  4,10,11 

Aulopsy  :    llxtr.llie  -rad-  clironlc  inlerslllinl  nephiitls 

Iii.,,1  in  cma,  1    10  V<.     Aut..|.sy  :    Kxlr.m.'  u-ra.Ie  int.Tstltial  nepnrltis; 
liilTii^.'  pyel..n.'pluiiis. 


Cr.'a  I.'  |i.r  . 
1  'aialas..  low. 


atala^e  low  ;  .li.il  in  uienila.  4 


Craniotomy:  f.-ll.,wlni,.  operation  hecame  "™Y.M\'ro„'."'lvl.e"rb'i1l.m 
ill...!  uremi.-  convulsions  on.-  wek  later:  probal.l>  acut..  ..,\,i.  i  rD.iti.'n 
■  if  nepliritls  followinL'  elli.'r  an.-lbesla. 

S..1U.-  li.'Uiatiirla  ;  no  iir.uiii.-  syMipl.juis  di'velop.'d. 


Had  -ympl..insou  a.l;iii"l..n  ..f  sli-lit  .-er.'brai   b.'in.irrhas 
cllui.iilly  consld.led  verv  i;rn\i    nepliritls. 


lllood-pressure   not    hUb :   cmsider...!   cllni.-allv    t.i   have    onl.v    a    sllfht 
ixrade  of  nephritis. 


•A» 


i) 


;?2 

In  mopt  of  the  cases  of  this  series  t!ie  time  of  appearance  has  been 
markedly  deUiyed  and  the  output  of  jihthalein  markedly  decreased;  where 
the  output  is  lowest,  the  delay  in  appearance  is  most  pronounced.  The 
time  of  appearance,  hnwcer.  is  not  so  imjioitant  as  the  amount  of  excre- 
tion. Details  of  some  of  these  cases  demonstrate  the  accuracy  of  the 
phthalein  test. 

S.  n.  G.  iXc).  25,  Talilp  St.  ajroil  i>.T,  surgical  No.  ■2.'i.lT4.  Adiiiittcil  Pec  21. 
1909.  complaining'  of  difficMilt  lUid  freiinent  urination.  Ilic-''  nriiiarv  ^yn.i.tnni- 
were  ilcpencl.^nt  on  ))ro-latic'  rnlar^rcnicnt.  tlie  residual  nyiiic  anio\intin;j  ti>  410 
c.c.  Patient  wa-i  apparently  in  L'ood  physical  conilitmn,  will  nourislie<l  but 
gliylitlv  anemic.  Trine  ^li,L•lltly  cloudy,  acid,  specific  firavity.  KIlOi  no  supar. 
sliL'lit  trace  alluiniin  and  no  ca~t-.  Irinary  output  2.()i'0  c.c.  in  twenty-four 
hours,  urea  ran^-iuK  from  20  to  .■!!)  f.'in.  for  twenty-four  hour-.  'I'lie  phthalein 
test  was  {-iven.  a  faint  trace  appcarint:  in  fcu-ty  niin\it«s  and  at  no  time  was 
more  than  the  merest  trace  detected.  Hepeatcil  suliseipicnt  te-ts  yielded  always 
the  sanu-  result.  One  week  after  admis^icm  he  hcfiaii  to  exhihit  siiins  of  uremia, 
which  frradually  increased  until  deep  coma  endin;;  in  death  sup.Tvcneil.  .\iitoiisy: 
Hoth  kidneys  pre-^ente.l  markeil  atro]diy,  neither  oiean  w,i,i:Iiinv'  onethird  of 
normal,  a  s'cvere  •.-lade  of  interstitial  nephritis  heiiif:  present. 

Thi.s  case  is  of  jiarticii'nr  interest  hecav.sc  of  tlic  fact  tliat  the  urinary 
output,  the  urea,  the  total  solids  and  the  total  nitrnjren  wero  roriiia!  and 
ciists  wcie  also  absent. 

The  fullnwinj:  is  a  history  of  a  case  in  which  the  dia::ni)sis  wa?  pcr- 
fcctlv  apparent  clinically  but  in  connection  with  wliieh  the  test  proved 
a  stnkinfr  confirmation  as  the  ]ilithalein  failed  to        eliminated. 

Mrs.  W.    (No.    12.  Table   8).  nf-'ed   21.  admitted   Nm .  ,.       Hh  Bymi)toni« 

of  \iremia.     Patient  had  had  eclamji'^ia    in  May.  ]90!i.  and   liad  ne\  "■    reeiiv- 

ered    her   f(unipr   health.      SiitTered    from    fre(|Uent    attacks   of   epi<i  -pnea. 

putrine^s  of  pvcdi.ls  and  edema  of  ankles.  On  examination  marked  em:,  ion  and 
pallor  was  not.d,  Ke.l  blood  corpuscles  l,nnn,nnO,  hcmo;;lobin  22  per  cent,.  hi?h 
.rivdo  "f  "'•-■  '  d;-k-  bio  ,:!-i)rpsvure  230.  temperature  normal.  Trine  was  some- 
what decreas,  ..  pecific  triavity  1013  to  ini9,  albumin  1.9  -m.  to  the  liter,  no 
casts,  acetone  and  diacetic  acid  positive  at   times. 

The  phthalein  te=t  was  (;iven  the  ^lay  after  adniis-ion  and  -bowed  entire 
!ib-p>ice  of  elimination   dnrini;  two  hour-. 

De-Jiile  vi^'orous  treatment,  coma  became  ileeper  and  death  suiHTvened  five 
days    later, 

".\utopsy    (3400)    showec'    an    extreme   fjrade    of    inter-titial    neidiiitis    with    a 
sU]i(-rimposed  acute  hemorrhafjic  nephriti-, 

Tn  the  folIowiuL^  case  the  diai:nn=is  was  cxcc^linLdy  obscure  until  the 
evidence  hrouL'ht  forward  by  the  test  was  added.  Before  the  administra- 
tion of  the  t'-st.  mphritis  was  only  one  of  many  possibilities  entertained, 

Mrs.  0.  (No.  22,  Table  S).  aped  47,  admitted  March  23,  1911.  In  October.  1910, 
noted  fati-ue  am!  dyspnea  on  slight  exertion,  toirether  with  sli.Tht  edema  of 
hnver  extremities.  In  Tlecember  nausea  and  vomitinji  developed  and  have  lieen 
pre-ent  almost  con-lantly  since.  On  examination  patient  was  poorly  nourished 
and  showc^l  m.arked  anemia.  IWM  blood-corpuscles  1  ,.500,(mil ;  hemo^doldn  15 
iier  cent,;  white  lilond  c.dls  fi,000;  -lijiht  inerea-e  in  cardiac  ihilness.  apex  slichlly 


i) 


33 

ao«„  an,,  out,  .ii.i.t  >>.to.i.  ■.,,,,■„,„.  ■"  H;;;'-':>,-;,;L:'^::r ::!  ::!::t 

tie.     Urine:    Pa•^^■-•l'- •/I-''-  i;:^^;\  5 '''V^etri:    negative.      AUho,„h 
.epca,f,i   ex,„mM„ho„.      '''""'H-  e-uro    Uo.      ^H  .  „„ln„„inont  danger. 

„aus.a,o,i  the  ,.at„.„t   «a.  "'^  '    'f  ;„,;^'    m    s      T«o  davs  later  tlu-  patient 

:::r':::;t;r^t::?:;;::::'-:;^^^^  -".-^ --  --•--  ^^ 

autopsy  "as  obtained. 

Chrotti.  ttephvitis  .an  ..i.t   ov.r  a   Ion,  ,,en.nl   without   ro^^Rni^nn 
..nd  tnav  ovon  .xi-t  in  tl,o  al.ene.  of  allu.ntm  an.l  .a.t.  m  tl-  -  n.      Th 
followin,^  i<  another  .a-o  ilht.tratinj:  the  pre.en.o  of  n^P'^'t'^J^"  Z*^; 
Iwnco  of  po.itno  -lini.al  proof,  and  also  the  value  of  tho  phthale.n 
toft  in  rcvealini:  it>  c\i.-tonce. 

V    r     ,\-„    n    T.lde  S^    a-.d  71.  "Lo  l,ad  had  .=^ix  previous  admissions    (for 

I.,  f,.    iNo.   l.i.   l,ii>i.        -a,-  artliriMs   dc.fonnans)    dunn-  tlie 

„,alaria.   fel.ricula.   a-ute   rheunmUe   t.w      l'"'^""';'  ,   „f   {^,  „„,,   ,egs, 

last  nve  years    «.s   ^;^-'   -  -      l^^^^  ;J;    '^  l^,,   ..inalyses  dur.n.  these 

vertigo  ani  a'taeks  of  loss  of  .onstiousne    .  albunun  at  one 

..missions  .uied  ,0  ''™-;:™-,i"::,::°::::;^o:^'r:;iSridid.pressure  ...re 

sin-le  exannnat.nn.     -^n  -"l;''"™"  '"  „.^,,    emphvsematous,    the    heart 

recorded    ..n    prev.ous    ^'-  >"'-.n   -•       '  ;,  ,  ^l  ,J,    ,   .»,  .  '  Trine:    pale,    specific 

:r;'  z"!z  °: :;«:  ::;*'" ;;."-  vi «. ....  *-  -....  - 

•rranular  kidney. 

The  followin.'  .a^e  is  an  examplo  of  the  difl'iculty  eneountered  at 
ti,,!' in  d!l;:;;:;ui:Hn,  .UnieaUv  vanon.  for.tts  of  toxemias  frotn  true 
nephritis  with  uremia. 

.    ,-       V       ,-    T.,l,h.  s,     .,...d   00,  a.lmitted  .Ian.   :!.    lull,  in  a   drou>y    toxic 

pressure   160  mg.     The  physK-al  ^7'";"'  ■\°;;  "^pe  ific    gravity    lt,3n,    acid. 

--    ".y-arditis.     T..e    >u,ne    ou.p        ^  J;^f];^^  The^ysician  in  charge 

albumin  4  gm.  to  the  hte..  'J-''"^  ".^     ;  .„  „,„„i,.   „nd  treatment  for  urem.a 

made  a  note  saying  "patient  .s  eertainU  m    .                                                        ^^^^ 

f,„.  two  hours  which  >"<'"■'"•;  '"  „,,  ,,,rtnite  physical  signs  of  a  pneumonia 
,,ter  the  t-U-tur..  K-.e  to^  UU  ^  '  li^^umonU  but  exhibite<.  myocardial 
':::Z^:rZ^\^I-^^^^oZ:  a,mo.  identical  case  of  pneumonia  in  which 
the  phthalein  cleaie,!  U|.  the  d.agnosi-. 

-rho  following  ,a.>  shows  oven  n.ore  strikingly  tite  ahilitv  of  the 
„uinleM,  tect  to  .-eveal  the  presence  of  nephnt.s  m  tne  absence  of  anj 
Sle  cl!:ieal  evidence,  heing  a  case  in  .hioh  nephnt.  wa^  not  sus- 
pected hefore  the  nd.niniMration  of  the  test. 


«• 


fy> 


Aiii.n  »  -ruTHAi.r.i.N   oititt  in 


1 — Miss    s..    seed 

57.    TSSSl 
2— M,  A..  BB.d  33. 

T.'.r.r.n 

3— N.  K  .  used  43. 
T34(il 


4 — MI'is   W  .   aired 

HI.     7."74-' 
.-.— M.   .\I..  :iL'.<I  37 
7."!l'.li) 


Il.Tlc 


Clinical  rcpiiditliiii. 


II  W/10 

11  3(1    10 

It  ti     111 

II  14    III 

II  7,1(1 


II  !»  ,   HI 

II  :.'n  1(1 

IL'  3/10 

I  7    II 


II.  c  .  nci-d  3rt. 
7ti4!iti 

1  ;'    II 

I  r.i  11 

1  L'7/ll 

A    T.  !IL-(d  43.        IJ  13/10 


»<  -C    (;..  aRi'd  '^H. 


I.    M.  T..  need 

Oil. 

-II    r..  ()..  ased 

47.    77441) 


Ki- 
ll 

IS- 
IS- 


S    B.  r,.,  ngod 
.-..-.    S.  •.'31.4 

M 

■T    K.  iiLvil  37 


IJ    r.i    In 
7    II    111 


'7/11 
^7    11 


1-'  '17/li!> 
1  7/10 
I    14   10 

11'    (i/(l!» 


3     1 1 
7     II 


14     W    .1  .  nii"d  71. 


ir>- 

ir.- 
17- 

18 
1 


V,  «• ,  ac-d  «T 
S.  ;:4!l.-.8 


■W  .  ni;r,l   .).-, 
•J.,  agi'd  3a.  . . 

—  r>r,  S..  BBPd  43 


in/U 
1  U/ll 

LVll/10 

"."IS/HI 

3     H     10 
.1    IS    111 

II  14  on 

II    L>4   Of) 

11'  ir.  00 
1  •Ji/io 


4  in  n 

.V  J/ 10 


4    II    11 


4    I.".    11 


Ac.  eiacpibatldn  of  a  ehr.  oephrllls  ;  edema 

In   uremia  ;  druwsy 

Syphilitic  n.plirltis  ;  dyspnea 

rrenilc    

HloiM.  prissiirc  21'(i ;    hod   had  siippresVlfin 

and  slight   drowslnesN  snme  days  previ- 

ciiis  to   ti'st  ;   no  signs  n(  ureiiiia   when 

I'-t  Klyen. 
Xansea   and    vomiting;   hlth.^iade  choked 

disk  :  sever-'  aneniia. 
Kdenia,  nervousness,  headache  ;  blood-prea- 

suri'  L'l.'i. 
Nausia     and     vornlilnK;     decreased     urine 

output. 
Ilypnthjroldl-m  :    nausea    and    headache; 

liloml-pressure  llii-I25. 

Condition   tinelianu'ed   

HyilrarKyrlsin  iicuti'   

Hitter  :  no  nausea  or  hendaehe .[ 

C'-nernl  anasar' ii :  luvocardllls  ;  arterio- 
sclerosis :     mitral     Insulllclency ;     blood- 

•■     ■sure  IfWi-iJL'ii. 

To  slilered  to  have  Incipient  uremia 

-Nausea,    voiiiltlni:;    chr.     pareuchvuiatous 

nephritis. 
Nausea.   sllKht   he.idache :  ihr.    Interstitial 

nephritis:  visual  illsturliunce. 
Marked  anasarca  ;  nausea  ;   hlood-iiressure 

1311:     no     edema:     chronic     Interstitial 

nephritis. 

Sllfht  headache;  nausea  in  morninu' 

.Mentally  clear;  hypertrophy  of  prostate.. 

<hr.  interstitial  nephritis ;'  svuiptonis  of 
uremln  aiipeared  one  week  after  test. 

nilateral  calculous  pyonephrosis ;  nausea 
and  voniitlni:. 

T'ni'er  hycl.  rapy  some  Iraprovement : 
nan-  .i  and      .luliinu  lieiter. 

Htl'    ■..      "r 

A|r    II      orp  uremia , . 


i  - 

He 


s- 


-Mb'iniln. 


pyolo- 


20—1.    R.    I...   (Red   !     4  23   11 

.Ml    -'KH■^ 


nL-iii    I. 
7430 


r.   .'<.    II 


'     3   31    11 

25-  r..  niied  27 I   12  lo/lo 

12/10/10 


Cnrclnonia     of     prostate ;     double 
nepiirltis  :  siluht  nausea 

llns  tiiiiisea  and  some  voinltinz 

■Mu  h  liettt.r;  no  nausea  or  yoinltluR 

l-'eils  Well;  Kineral  condition  exc.llent .  .  . 

UypiTlropliy  of  prostate;  septic  tempera- 
lure. 

Drowsy;  tempiTature  septic:  iiretuie 

Better;  not  uremic;  evening  temp.  100  F. 

GoimI  eoi   "Itlon 

Pyelonepi. rills  of  solliiry  kidney ;  'Vom- 
Itlnr  and  nausea  severe. 

In  fair  condition  ;  no  symptoms  of  uremia. 

Acute  nephritis:  edema;  sinHl'  urine  out- 
put, nut  uremic 
rUr.    niplirltis;    marked    cerebral    arterio- 
sclerosis;   lilood-pressure   2ti(i   mm.    Il)t; 
no  sl«tis  of  uretula. 

Hypertrophy  of  prostate;  moderate  resid- 
ual:  history  of  uremic  altmk  one  year 
lirevlouslv  :   Klvi'n  an  Intravi  uuus  Injec- 
tion of  phthaleln 
Arierlo.cli  rosis ;     (hr.     nephritin ;     hlwd- 

pri'ssiire  11III 
rhr.    Interstitial   neplnltls;    hliuul  pressure 
l-sii-i'iiii;   hiiiiorrliiiulc  nthiltls;  u'en.ral 
anasarra  ;  iienleraie  nausea  ami  voinltinK. 

Iilaimiis<'d  dialietes  Insipidus  on  udmls. 
slon  :  blood  pressure  N5 ;  no  »li;u  of 
uremia. 

.N'othlng  to  suntest  nephritis 

Hypertrophy  of  prostate  ;  pyuria 

Ilai  suiDe  ttrrt ;  aomrwhat  dtvwsy 


14 


SO 
133 

i:i4 

30 
152 


48 
130 

34 
127 


1.009 
1.012 
1.011 


1.008 
1.014 
1.012 


11"   I    1.010 
l.lllO 


170 

nil 


on 

lIMI 


100 


1.01 

l.olo  I 


1.012 
1.008 


40       ...    I    1,010 
Ijo   j    •••        l.olO 


00 

.•.o 

23 
1(1 

;io 

3S 

1.1 


123 

123 


l.<0 

Jill 


1.012 
1.022 


1.018 
1.008 


2.W       1,012 


130 

i:in 


'  No    est, 

t  K»crel 
snllds  noroi 


1.012 
1.014 
1.014 


t      I    

434   j  1,005 

3!)0  l.oim 

200  '    


225 


-I-  + 
+  + 
-f-f- 
-r  + 

-f- 


-I- 

-f--l- 

-f -4- 

Trace. 

Trace. 

Trace. 

Trace. 

m  to  L. 

+ 
-l--f- 

+ 
Trace. 

Trace. 

+ 

+ 
-I- 

+ 
+ 


120 
230 

340 
4S0 


1.020 
1.010 

1.003 
1.008 


+ 
+  + 


Trace. 

+  + 


loelve  iiiiurs  nlirr  Injection  phthaleln  was  still  lieinir  eirretel 
..nt.  Ill  three  bourn  and  40  per  cvot.  for  i  'x  hours.     Urea,  urinarv 


iiitpiit  and  total 


#)■> 


rui:Niv-FivK    c.\si;s    ok    ikkmia 


'     r«'rrt>n(a>:t'  nf 


Mtc-ns.'*tpli'al 
rindings. 


One  Two 

Hour.       Hours. 


Vuni'roiis  costs. 
Ni  mcrous  casts. 

I  'W  casts. 

1'.  w  casts. 

I'-w  casts. 


No  casts : 

f-  w  casts. 

1*.  \v  casts. 

Kfw  casts. 

lew  casts. 

K'-w  casts. 

[■'■w  casts. 

(I 

NiiuicrnuM  casts. 

Vi:mcrons  casts. 

\o  casts. 
Jew  K.  B.  C. 


I  loudv  from  p\is. 

I'loudy  from  pus. 

tlniidv  from  pus. 
I  lijiirty  from  pus. 

I  tnudy  f  ri  m  pus. 

clnudv  from  pus. 
Cloudy  from  pus. 


Cloudy  from  pns. 
Cloudy  from  pus. 
Cloudy  from  pus. 

Cloudy  from  luis. 
N'unicrous  casts. 

Numerous  casts. 
Some  '  Bsts. 

Casts.  i 

Numi  reus  cisti. 


« 
I'us. 


;i.i 


IS  (I 
■JO  4 


II  i; 

.■(.8 

".1.0 

4.(1 

8.(1 

20.(J 

20.4 
0.1) 


.-..CI      I 


Trace. 
Trace. 
Trace. 

I'racc. 

1 1.0 

0.0 

Trace. 

.-,..-, 

(1.(1 

triiie. 

Traci'. 

ISIt 

:'.,-5.2 

1     14.S 
40.0 
72.4 

.... 

'  S.fi 

2:1.0 

37.0 

I       R.o 

(to 

ISO 
20.0 

27.0 

i 

1 

0.0 

0.0 

1.0 

4.0 

1N.5 
■.0 


3.0 

4:in 

13.0 


I'iiUciit  recovered  in  lew  'luys  after  last  lest. 
;;.'l..)it>  herself  f(.ellii);  well :  .  .lenia  sdll  present, 
lii.d  l\l(i  HI;  coma  develu|)e(i  11    15,  l(i. 
.Viiiopsv  :    Seven'  amyloid  neplirltls. 
111.  U  two  wielis  later;  no  autospy. 


i    llii'il    II    H    10,      Aul"i'-v:     Si.iiiM    j;raliiil:ir   kidueys   witli   superimposed 

aeule   nephrllis. 

Iteport  4   14  11,   iu  bad  condition;  uii:ilile  lo  cet  iil.out  ;   nausea.  Iieud- 

lolie,  iMc. 

Disclnuxed  2  7  11  ;  lieiul.-o 'le  and  niiuse.i  heiter  ;  illeil  iwo  iniinilis  iiii-r 
ieaviut;  litspilal  will)  symptoms  of  uremia  ;  uepluitis  was  only  reyarJc  d 
as  u  possibility  In  this  case  until  plillialelu  test  was  performed. 

I'iiti'iit  left  liosplla!  in  I';ilr  cnii.iition  :  ur.  iiiia  did  not  develop. 


No  dnn:  in  four  hours;  died  iwo  ilays  later  In  unuula. 

I'led  In  iir-iaia  4  17   II. 

r,ee:inie  drowsy  :;  J7  '.ii;  i!i- li  In  uremia  4  1,  Ifi. 

Uled  l.'I'.i  11  In  uremic  coma,     .\utopsy:    Kitreme  grade  chronic  Inter- 
stitial nephritis  and  diffuse  iiyelonephrltls 

Died  lu  uremic  eonvnislons  two  months  later;  no  autopsy. 

lioulile  nephrot v  done  rapidly  under  ens  111   11   In  hope  of  slvhm 

some  rellif;  dii'd  In  ui>mla  ivltlilii  t». my  four  hours;  kidneys  were 
Ihln-walled  pus  sacs. 


For  three  hours  total  excretion  IIS  per  cent. 

Kor  three  hours  total  excretion  2."..1  per  cent. 

I'erinenl  pro.liitoioiov  for  remonil  of  obstruction  :!  '-1,10. 

Mini  Uvlni;  :!  Ill 


I'erinenl    prostato'omv    12,  22  nit ;  nood   recovery;   sllll    living.   In   irood 
condition.  :<  111. 


Omdillon  betame  worse  .iin!  dli .!  In  coma  one  week  later 

Cranial  exploration  4  It  II;  fullowlmr  oriernllon  (eth"r  nne«tli.-lai 
was  droH  sv  and  loid  verv  low  orlniirv  coilput  ;  died  uremic  .■onvulsloiis 
one  Week  Inter.  pro|,iililv  a.  ute  eiiicerliation  of  Ms  ehroiile  neplirltls 

l'r,istatec!i  niv  under  lonit  I'th.r  anesthesia  4  111  11;  suppres- on  of 
urine  at  once;  dl.-il  4/20/11  ;  ni>  mit..p-y. 

I'rea  l.')!  ;  died  In  uremia  two  da.is  later. 
Iiled  In  iiri'mic  convulsions  two  we.ks  later. 

Tniee  of  nlloitiiln  found  etoe  prior  to  adnil'slon  ;  p..l.\urlii  for  two 
veais;  ahoot  t  :;  It  heiolaelo's  api.cared;  4  I/ll.  trace  of  nlbolnln  ; 
illed  In  ureiola  4  '.'  tl  Nutopsy  Kiir.ine  grade  of  chronic  Inter 
mtlal  nephritis;  practically  no  renal  cortes. 

Died  about  ten  days  after  last  test  of  uremia  ;  no  oi»'ratlnn  .Xutopsy  ; 
Old  chr..nlc  pvone|.hro«ls  of  left  kidney  ;  rluhl  kidney  hvpertronhlid. 
■bowlD(  cbr.   dirr     nephUtls   iiri.l    niiiiU.d   diffuse  acute   pvelonephntls. 


«.v 


..iioni  r<.i 


..Ki  tr.rr,- 


l  rir«l  half  hour  'J:>  |ht 


ntnl  ex.rctlon  for  one  hotir.  :!T  per  cent. 


to  tlTC  ir.tr.ntr-, 

cent.     Normally  (his  nni.  h  c».  1.  led  in  !.■ 


than  (en  tnttintes. 


*) 


36 

r..  C.  iXo.  24.  Talile  8).  115;.. 1  12.  aciniittcl  March  27.  1!U1,  a^  an  intercstins 
ease  uf  .lial>oti'.s  in.sipiiliis.  '1  h,.  pa-t  history  contained  notliin^  "f  importance 
except  that  hirj;c  quantities  of  urine  had  lioen  voided  fur  some  time  and  he 
expeiienccil  marked  thirst.  !i.  was  well  nourished,  n.t  anemic  and  apparently 
a  normallookin^r  boy.  His  blood-pressure  ranged  around  IW)  mm,  ]!;.'.  Some 
thickening  of  the  radial  arteries  was  noted;  no  definite  eyecliai!  -.  'I'he  urine 
<m  admission  was  large  in  amount,  fiom  2,iKHI  to  2,5(10  c.c,  clear,  rcific  gravity 
ll)M.5-l(rI(P,  A,)  nlhumin.  ii<i  nis/v.  M  this  time  no  suspicion  n.  nephritis  w,i"- 
entertained,  altliough  ;;  trace  of  allaimiti  hud  been  noted  once  previous  to  admis- 
sion.  'Jlie  phtlialein  test,  performed  March  2.><,  showed  an  output  of  only  7  per 
cent,  for  two  hours.  'Ihree  <hi\s  later  only  ;)  per  cent,  was  e.'icreted.  With  the 
exception  of  the  phthah-in  finding-  alisolutely  no  evidences  of  lu'phritis  were 
present  at  this  chile,  .\  week  later  he  developed'  headaches,  and  a  trace  of  albumin 
in  the  urine  aiipeand.     He  rapi<lly  became  uremic  and  (li>>d.  April  H.  I!)ll. 

Aufo]i-y;  A  nio-t  inlensi'  grade  of  chronic  intersliti.il  nephritis  was  present, 
uith  almo-t  (omplete  di-appearance  of  the  corte.\.  A  sliglit  grade  of  acute 
iii'[i|ii  ill-  wa-  -nperim|io-ed. 

n;i:MiA 

In  twtiitv-fivf  rases!  iiikIoi-  study  iircinia  lias  \wn  present  (see  Table  9). 
In  .-i.\tcon  of  these  the  uremia  was  ■^\d\o.  tho  patients  exhihitins:  nausra. 
voniitintr,  drowsiness  or  coma  ,ind  111  several  iii-tanres  convuisions.  hi 
the  reinaininrf  nine,  mild  symptom-  milv  wore  present  ami  liail  persisted 
over  loni'  periods.  Kloven  >•(  the  sixtoiii  patient-:  with  L'lave  iremia  died 
dui-inLT  the  attai  k.  /;;  ti^l  nf  tins,'  nisi  .■<  Hit'  plilluih  in  1 'Imnuitinti  irns 
zero  III-  11  faint  iraic  onlij  for  two  hours. 

Of  the  five  fiatients  recoverini;  fioin  their  uremia,  in  two  insfarifes 
the  output  was  'iO  pei-  cent.,  ti'o  uremia  licim:  the  res^dt  .if  an  aeute 
e.xaeerhation  of  a  chronii'  nephritis.  In  two  tlie  <uitput  was  14  per  cent.: 
in  hoth  of  these  the  uremia  was  prceipitatoil  hy  a  ilnuhle  p\clonephritis. 
'I'l.c  fifth  ease  v\a-  an  amte  e\ai  cvhatinn  in  a  case  of  chronic  pvelo- 
ncpliritis  in  a  man  [previously  havin,::  had  a  iiephrectomv.  This  Ia<t 
patient  ha-  L'lvatly  improved  hut  at  present  has  ^  two-hour  excretion  of 
l.'i  per  cent. 

In  niihl  eases,  exhiliitiiif:  sli<:ht  hut  persistuii:  symptoms  of  nnmia. 
the  excretion  respectively  wa«  ns  follows:  10  per  cent,  in  one.  T  per  cent, 
in  three  case*,  a  trace  in  one.  5  per  cent,  in  the  other  fnr  two  h,  iirs.  Four 
of  the  jiatients  died  within  three  months  of  the  performance  of  the  test. 
Those  livin?  are  still  exhihitinj;  evidences  of  chronic  tiremin.  fciir  month.s 
havinc  intervened  in  one  instance. 

In  five  patients  who  did  not  cxhihit  nninia  at  the  tun.'  of  the  test 
hut  in  whom  the  plitlinlein  output  was  below  s  p,  ]•  ,  ent.  for  two  hours, 
one  cxcretinir  (>  per  cent,  died  within  two  ninnths.  one  e.vcretinj;  .1  per 
cent,  in  one  month,  and  the  others  are  still  livinfr.  one  after  four  nionth=. 
one  after  two  months,  ami  tbo  other  after  three  weeks,  hut  all  an-  nt 
[iresent  cxhiiiitin?  evidence  of  chronic  uremia. 

In  two  patients  (Xo«.  1.S  and  10.  Tab!"  <))  not  exiiihitin.'  uremia  but 
with  a  markedly  decrcnsed  pbtbalein  outjni.  (i|ieralinn  with  Ions.'  ether 
anesthesia  in  each  instance  waa  f.dlowcd  li\  uremia  arnl  death. 


CAliDIAr      AND     I'AIiDlOliKN'AI.     (  A.Si;> 

An  alloiiipt  liU5  lieen  inaile  to  tliirorentiau-  b\  iiican>  ol  this  test 
l)elwfen  lliose  Lardiac  cajtr-  with  hnikeu  (oiiipensation  and  passive  con- 
gestion of  th.'  kidiiev,  associated  with  tlic  presence  of  albumin  and  casts 
in  tiie  urine-  and  tliose  cases  in  whicli  cardiac  insufficiency  is  associated 
with  varying  grades  of  true  nephritis.  Jn  tiiis  lonncition  thirty-th.ree 
cases  have  been  studied.  Tiiere  were  eighteen  cases  in  wiiicli  the  purely 
rUnical  diagnosis  was  that  of  uncomplicated  cardiac  disease,  and  (ifteen 
cases  of  cardiac  disease  associated  with  ne|iliriti.-,  I'lnm  a  study  o(  these 
cases  there  appears  to  be  no  doubt  but  that  decrea?e  in  function  accom- 
panies marked  passive  congestion  of  the  kidneys  in  the  abseuce  of  any 
true  nephritis.  As  the  cardiac  condition  improves,  liowever,  the  passive 
congestion  i)ecoming  less  marked  and  edema  subsiding,  the  output  of 
phthalein  increases,  and  in  one  case  rose  from  1(>  per  cent,  to  normal  in 
the  course  of  one  week,  the  patient  in  the  mcaniime  lo-inv^  .-evcntv  pdiinds 
in  weight  with  the  disappearance  of  a  general  anasarca. 

The  opportunity  of  comparing  the  result  of  the  plithalein  test  witli 
the  findings  at  autopsy  was  afforded  in  tlir  fnllowiiig  (  ase: 

II.  H.  (No.  7(iT10i.  !i^.-,l  -JH.  luhnitti'il  -hui.  'iO.  lllll,  i-oiniiliiiniiin  of  -cvoii' 
clysj'iioa  ;i!i(l  >-««'lliii^r  "l"  f>'<l  «liicli  lind  cxisleil  fnr  t\vi>  week*  only.  I'livsit'ul 
.xaminntion  revcalo.l  iiKirkcilly  imioase.l  oardiar  (liilnc<>.  mitral  ami  aortic 
insuffic-ipiuy,  dilatation  of  the  l.cart.  wmc  ascites.  lironi-lio|MiiHimonia.  bloodpri's- 
~iMc  mo.  moderati'  iirade  of  swondiiry  anemia.  Irini-:  liigli  ooloreil.  specific 
-ravily  lO-tti.  acid,  aliiuinin  +  +  +.  larj;e  numlier  of  hyaline  ami  f.'raniiliu-  casts, 
riitlialcin  test  showed  an  olil|iut  of  21!  |).-r  cent,  for  t^^^  honis,  Pali. tit  died 
un  the  I'.iv  followinj;  admission. 

,\ulo|i-y:  (  hronie  mitral  and  aortic  endocarditis,  chronic  mycpcarditis,  marke<l 
hxperlrophy  and  ililatation  of  the  heart,  a  moderate  jirade  of  chronic  difTuse 
nephritis,  with  some  Miperimp.>sed  arntr  mpliiilis  Dctli  in  ihis  in-taiic.'  was 
in  L'reat  pari  dne  to  cariliac  failnre 

In  those  -ases  witli  l.r.'keii  ,  ,iiii|ieir-,il  inn  \vlii(  li  presented  a  high 
phthalein  e\  tioii.  m  nearly  every  instance  albumin  inid  <;i-ts  entirely 
ilisappeared  with  the  improvement  in  Mie  cardiac  ronditimi.  \n  .'vample 
of  this  cliiss  is  the  following  case: 

I  he  pal  nut  r.  \V..  presented  n  severe  itrude  of  ({•'neral  nnnsarea  with  nlhuinin 
and  ca-ts  in  tl.e  nrinc'  at  the  lime  of  the  te«l.  lie  excreted  (W.S  per  c.nt,  nf 
phlhahdn  in  two  hours.  .\i>  (he  anasarca  dwreaseil.  alhtimin  and  casts  entirely 
disappeared,  the  Kidncv-  showing'  n..  prrnian.-nt  injury  fmni  the  hreal>  in  com- 
pensat  ioir 


The  presenie  of  a  L'eni'ral  jna-iirci.  particiilarlv  when  rdi'iiiii  exist!" 
at  the  point  of  inj(><tion.  probably  introduces  some  error  from  tlio  stnnd- 
peint  of  absorption.  The  extent  of  this  error  luis  vet  to  he  determined. 
Fniin  a  slndv  of  tliese  i  ns,.s  we  feel  that  tin'  phtlnih  in  lest  will  prove  of 
value  in  determininL'  what  de^'ree  ..f  nn,i!  in-ulVu  iency  exisf«  in  (hi*- 
elflsp  of  disi'ase. 


«:• 


t:. 


38 

With  inip.iivrMitiil  in  the  laidiai  coiiditioii  aud  the  disappearance 
subsequently  of  edema,  a  loiitinucd  low  phth:  'i>in  excretion  will  indicate 
with  lonsiderablr  .  .itainty  the  jjic'^ence  of  [v.  iiiiaiient  organic  changes 
in  tlie  kidney.  ;eel.  however,  tliat  a  inucli  larger  serie'^  should  be 

>tiulied  clinirii  nl  iit  avitopsy  l)cforc  very  (hfinite  <-onrlusi()ns  can  be 

drawn. 


Tahik    10 

—   Illi;     lUlMUiN      Hi       I'ilTMAI.KIN       OlTl 

IT       111       Ml 

'  1 

'ill  .■■^rni:.     TO 

IM.WI.IS     IN     TIIK    KyK  fiROl 

\n.S     .\M)     Ml 

nil.   liiiMin 

I'KT 

10: 

l';.li..lit 

\'\  .'  (  II  nuilll^ 

-■v-l. 

i:.M 

nil. 

I'litliali'iii 

liiiMid 

Ol!- 

I'.'T 

(lilt  put 

I'li'—mi' 

.  .'lit. 

I'lM    I'Pllt. 

.\lr>.   V. 

.\t   pn-^iMit  nonn;il 

220  :iSll 

32 

lliinv    li. 

IKO 

a.joo.ooo 

00 

2(1 

Tr.  »  . 

Noiiiiiil    . 

i-.'ii 

5,5.5  1   111. 

I.B. 

Ntiiniiil 

IOiMlVi 

4.0.tO.OllO 

7."» 

:!(i 

<;.  w. 

NcMIIKll 

s.-.  1 1 :. 

-t.oiiiroHo 

7.'i 

(15.8 

1..   K.  S. 

Ni'rni:il 

I.SIIO.OOII 

70 

48 

K.  X.  s 

\..rn::ll 

210 

:i.;ioo.ooo 

'.n 

40 

S.  1!. 

ISO  Jill 

3;!.:! 

(i.   !• 

i."i.l  170 

."..III  11 1.000 

00 

22.7 

1'.. 

-m 

1.000,000 

7.*» 

15 

1..  W  .    1 

!!.'.  1-J."> 

54.3 

S.  \V. 

\..rin.il 

1  10  |!M1 

t.200.000 

70 

30 

i;.. 

1  Imk.Ml  ill-:. 

ico-.'ls 

i.."i00.000 

H.'i 

52 

1!.  S 

l.l.'i  170 

4.000.000 

OS 

35.7 

C.   It 

so  i;io 

.'i.  100.000 

OS 

44.4 

.1.  .1. 

Hir  110 

4.H00.00O 

so 

71.5 

!■•.   K. 

.   Ila/y   ilii-U-.   wliili'   -plulf 
:iiul  torliiDiis  veswl-   .  .  . 

ir,     i:io  IHO 

4.700,OIM) 

.'llf 

27.5.13.3 

11.  <;. 

80  120 
XO-UO 

4.2m).o(iii 

.■..000.000 

70 
105 

ti.lit) 

K.. 

.   KiloiiiH  nf  dUk'^ 

47.22  47.52 

.1.  s.    . 

Hlli-.'IO 

2.700.000 

42 

20 

.1.  s. .    .  . 

ISO  220 
i:io 

i.->oo.(H)ir 

15 

34.7 

Ml-,   o 

NiKativi- 

0 

.\.    T 

Niiriiia! 

KM)  ISO 

4.r)Oo.ooo 

7s 

20.H 

U.   K. 

170  21.-> 

1.700.000 

Its 

5 

!..  W 

2..100.000 

3(1 

(lO.O 

II.  1.. 

.     \<').Mtivi' 

110.  no 

4.200.000 

(12 

3.S 

M.    \, 

.   N«*vtitiv(»                       .... 

.  ..      100120 

:i  400.000 

55 

1 

(!.    II 

Dim  Diitliiic.  old  liemorrlmgie     HH)'-.>-Jlr 

33 

rt'l  initio       

1'.  S. 

Netwt  ivi- 

OP  ill 

.">.2O0,000 

!14 

iiO.4 

('.  X... 

!I0  170 

j.tioo.ooo 

SO 

2li.3 

.1.  T. 

Ni'pillv' 

120  150 

1I2.O 

1!.   1) 

.    .\l')!Htlvr 

.'l.llOO.OOO 

(•5 

«5 

Ml-.  U  . 

(    liok.'ll    .ll      , 

2:to-  so 

l.OIIO.IHIO 

2'* 

0 

.\.    1 . 

.   Norntal 

IliO  210 

4..~)00.000 

fr 

20 

(;,  i>. 

.  Xoriiuil 

100  IHII 

.■..ooir.ooo 

74 

25 

!••.  (i.  . 

.  Niirmal 

22tl23,-i 

4.500.(MIO 

HO 

15.5 

S.  K.  . 

.  Noriiiiil 

liiO 

50 

r.  K. . . 

.  Niirniiil 

s.-i  loir 

:i, 200.000 

50 

0 

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J 1  .'> 

.'■1.21M1.000 

75 

11.  3 

n 

220 

40 

.M  i.>^(i;i.i..\.v  i;oi"8   I  ASKS 
.\    lame  niiMilMT  of   mippolloncoiio   inodiesl   disease!;   have  been   al.so 
studied  from  (lie  standpoint  of  phthalcin  evrrotion.  anione  the  numb(>r 
beinR  ten  rnse.s  of  lobar  pnetiinoniii.     'I'""  "I"  (h<vo  .tiip-;  <.\lilliiti.i1  nvi- 


39 

dence?  ol'  a  mild  nepliriti?  during  the  attack,  wliiili  wa?  associated  with 
a  definite  decrease  in  phtlialein  (ititput.  In  both  ease=  the  urine  was 
entirely  normal  one  ni^ntli  later,  a-  was  also  the  phtlialein  output.  In 
pneumonia  the  output  i-  little  i!  any  deereased  ami  lirar-  no  relation  to 
the  ehlorid  exeretion. 

Three  eases  of  persistent  albuniiniiiin  have  ^lloun  a  iionnal  output. 
In  no  disease  other  than  renal,  so  far  >tudii'il.  has  marked  rediuli.'U  of  the 
|)hthalcin  e.xerction  been  etuountiMcd. 


Till-:  i(i:i.ATi().N    OK   iMiiii.\Li;iN   outi'li    lo    nui()U-i'iii;.ssi-iii:.  to 
(•ir\Mii;s    i.s    Tin:    i:ye-grounds.    wn   to 

TtlE     BI.OOD-TUTDHK 

In  the  majoritv  of  eases  of  ehronie  neple',i>  in  whieli  the  l)lood- 
pressure  has  been  liijjli.  the  plithalein  elimination  has  been  markedly 
decreased,  but  no  e.\act  pnrallclisni  exist.s  inasmuch  as  not  a  few  instances 
have  bein  encountered  in  wliieli  the  s\stolie  i)rcssure  lia'  been  over 
•200  mm.  Eg  and  the  plithalein  output  one-half  of  nnrnial.  while,  on  the 
othci'  hand,  there  have  been  instances  in  which  the  blood-pressure  ha? 
been  normal  while  the  jilithnl.in  output  h.is  been  zero  or  nearly  so.  the 
patient?  sliortly  afterward  dving  in  uremia.  While  a  high  blood-pressure 
when  present  is  considered  of  dia-nostic  and  prognostic  vahip  taken  in 
.onjunction  with  other  clinical  data,  yet  many  patients  died  of  renal 
insuftlciencv  and  exhibited  a  blood-[iressnre  which  was  normal  or  prac- 
tically so.  Xor  is  the  blood-pressure,  even  when  high,  increased  in  inverse 
proportion  to  the  decrease  in  renal  function. 

Wliilc  in  some  instances  marked  changes  in  the  ey(>-grounds.  choKed 
disk,  tortuous  vessels,  hemorrhage-,  etc..  have  been  present  loincidcnt 
witli  a  very  low  plithalein  output,  in  many  case:?,  even  of  the  most 
advanced  and  even  fata!  nephritis,  no  changes  whatever  in  the  eye- 
grounds  could  bo  detected.  il'<'  ■■ntl.-nt  at  the  -aine  tin,.-  failinu  tci 
eliminate  tV.e  plithalein. 

Moderate  or  rather  severe  grades  »!  .-r<(mdaiy  anemia  in  ti.c  absence 
of  (license  .if  the  kidneys  can  be  pre-ent  without  any  diminution  in  the 
phthalein  elimination;  for  instance,  two  patients,  one  with  2..')00.000 
red  cells  and  hemoglobin  :!0  per  cent.,  the  other  with  lunioglobin  ;?0  per 
.ent.,  eliminated  •)!  and  'u  per  cent.,  respectively,  for  two  hours.  .\  dog, 
with  a  red  count  of  ;,390.()0(>  and  a  plithalein  output  of  ■*!.'  por  cent, 
for  one  hour,  was  bled  120  c.c.  resulting'  in  re<l  count  of  .'"..400.000  and 
no  change  in  phthnlein  excretion. 

VAI.0K    OF    TKST     PnOM      V     iJCRClirAl.    ST.WnPOI.NT 

Throu!.'h  the  encouragement  of  Dr.  Yonng  we  have  Iieen  enabled  to 
study  the  phtlialein  excretion  in  a  large  serie?  of  ca»es  of  urinarv  obstruc- 
tion, in  order  fo  determine  the  value  of  the  te«t  in  revealing  the  fune- 


'h 


•^ 


40 

tional  wpacitv  ol'  thf  kiaiua  iii  tln'^e  ca:^.-.  'I'lii.-  i^'  t  consideration  of 
-rave  iniportaiKO  in  tln>  coi  lu't  tion.  >inic  the  development  of  urenua 
or  renal  failure  ha?  been  responsible  foi-  a  ^reat  i-arl  ..f  tlir  ninrtalitv 
l'ollo\vin<:  surgical  interl'croncc. 

As  a  result  of  obstruction  in  the  lower  nrinarv  tra(t.  palholo.izieal 
changes  mav  occur  in  the  ureters  an<!  l<i(lncys.  dilatation  of  the  ureters, 
varyinj:  srrades  of  hvdronepbrosis.  and.  as  a  result  of  the  ■•ontinued  hi-h 
pressure^  atropb.v  o'f  the  y.arenclivnui  of  the  kidnev  Net  lnfr..qupntly 
infection  occurs  witli  th.c  development  of  a  pvelitis.  a  dilfuse  or  localized 
pvolonejihritis.  or  pyonephrosi<.  'i'be  occurrence  of  these  complications 
is  often  difficult  of  "recognition  and  is  often  overlooked,  particularly  in 
the  absence  of  symptoms  of  renal  inadequacy.  A  large  pr()i)ortion  of 
these  cases  of  urinary  obstruction  have  cystitis  associated  nith  albu- 
minuria. The  presence  of  casts  in  the  urine  i^-  no  cnntra-indication  to 
operation.  The  urinary  output  may  bo  normal  in  many  instances,  also 
the  urea  and  total  solids,  and  yet  tlie  patient  may  be  on  the  verse  of  renal 
failure  and  disastrous  results  may  follow  surgical  interference. 

The  test  has  been  used  in  at  least  l-W  (ases  of  urinary  obstruction, 
mostly  cases  of  prostatic  hypertrophy.  The  technic  involved  in  these 
cases  necessitates  the  use  of  a  eatheter.  otherwise  it  doe<  not  differ  from 
that  described  above.  For  a  detailed  consideration  of  the  vahu>  of  this 
test  in  relation  to  obstnulioii  in  the  lower  urinarv  tract,  see  O'lr  previous 
publications  on  the  pbthalein  test.'" 

In  the  majority  of  cases  the  test  indicates  more  or  Ich-^  of  renal  inipair- 
menl.  aud  taken  in  (onjunction  with  the  clinical  conditi.n  it  is  of  more 
value  than  the  ^tudv  of  urine  output,  total  solid-,  total  nitrorreii  ;nid  inva 

estimation  combined. 

A  marked  deerea-^c  in  the  amount  evcret*Ml  invariahlv  means  severe 
derangement  of  renal  function,  xvhi.li  nuiy  be  of  either  a  temporary  or 
permanent  character.  Knder  -uch  conditions  one  should  proceed  with 
extreme  caution  and  no  surgical  intervention  shotild  be  attempted  wilhou! 
further  study  together  •.  ith  preliminarv  treatment.  This  prcliminarv 
treatment,  ns  introduced  some  years  ago  into  this  clinic  bv  Dr.  Young. 
,-onsists  of  drainage  by  meiins  of  a  retention  catheter  or  frequent  catheter- 
ization, together  with  the  administration  of  large  quantities  of  water. 

T'nder  tliis  regimen  repeated  functional  tests  will  denmnstratc  even- 
tuallv  the  nature  of  the  derangement,  for  in  true  interstitin!  nephritis 
the  output  will  continue  low,  whereas,  if  the  derangement  is  purely  func- 
tional or  secondary  to  pvelonepbritis  usuallv  improvement  will  follow  as 
a  result  of  the  treatment  and  will  be  indicated  bv  a  decrease  in  the  time 


3rt    See  Rpferoncf  i.  nnil   ulso    \iui.  li    tnnt.  il.  Oil' 
\tnrch.  1(111.  nn.l  Tr.  .^m.  .'V-n.  r.on.rrin.  Siirif..  I'Mii 


I  i.'ii    I  T  in      I'l'ln  nary  and 


t^ 


41 

of  niipcaraiu-e  o!'  the  (Jni.i;-  ;iiicl  ^ilInllti^n(■oll^ly  an  inimi>c  in  the  amount 
I'liniinated. 

Thf-  functional  (h'iani;ciiiL'nt  tluu  to  inftvtinn  in  theso  cases  is  a  nuicli 
more  daniicious  condition  than  is  tlio  presence  of  even  a  fair!  ailvancwl 
■•ondition  of  inlerstitiai  no]ihriti.-.  The  u-e  of  the  test  enables  one  to 
select  a  favoiahle  time  for  operation.  In  cases  exhibiting  a  continued 
suspiciously  low  o\itpiit.  the  nse  of  nitrons  oxid  gas  or  spinal  anesthesia 
is  sn^'gested  as  preferable  to  ether  in  (U'der  to  protect  the  kidneys.  Wlien 
onlv  a  trace  of  the  dnig  continues  to  he  excreted,  operation  should  not  he 
attempted  at  all  except  in  an  emergency,  evi^n  though  th.e  patient  presents 
no  evidence  c'.'  tireiuia. 

In  our  original  paper-  we  stated  that  a  dropping  jjlithalein  <iutnut 
was  a  contra-indication  to  operation  except  in  case-  of  necps-ity.  This 
decrease  in  function  usually  means  some  ijiange  in  the  renal  condition 
and  in  most  of  our  cases  it  has  been  caused  hv  the  development  of  a 
pvelonephriti-  or  an  exacerbation  of  an  old  process.  It  is  obviou.sly  wise 
to  wait  until  the  kidneys  have  recovered  from  this  acute  slmck  before 
subjecting  them  to  further  injury  thrnuiih  operation. 

'•i:iv  Miv  oii>ri!rcriON 

.\s  recard-  the  amount  of  excretion,  hclow  which  one  should  not 
operate,  we  do  not  attempt  to  draw  a  definite  line.  Tiie  test  simply  indi- 
late?  the  renal  function  and  it  de|iend«  on  the  operator  what  risks  lie  is 
willing  to  assume,  the  probabiliticr  of  fatality  increasing  as  the  phthalein 
output  decreases.  We  do.  liowever.  recognize  when  we  have  low  function 
which  otherwise'  mav  he  unrecognized  and  have  found  that  preliminarv 
treatment  in  most  instances,  wliether  it  be  by  suprapubic,  perineal  or 
ratheter  drainage,  allow*  a  regeneration  of  function  which  will  be  indi- 
rated  li\  the  te<t  nnd  cnaMe-  the  patient  later  to  undergo  the  rr^iver 
operation  of  piostatectomy  with   less  risk. 

The  test  can  lie  used  to  eijual  advantaire  ju-elin  inarv  to  an.y  sur.'ical 
procedure  wliere  it  is  deem<^l  important  to  know  the  true  functional 
capacitv  of  the  kidnevs. 

Ti:(ii\ii'  Of  rin:  i'iitiiai.ki.v  ti-;st  as  Arri.iri)  lo  i:sri\i  \Tm\-  or 
nii:    Ki-Ncrios-   ok  tiiI':   ixnivini-\r.   KinxtY 

Functional  tests  have  already  deninn.-t rated  their  great  value  iu  tlii-< 
connection.  But  they  have  at  most  been  able  to  determine  (mly  the  rela- 
tive working  capacity  of  each  kidney  and  have  shed  verv  little  lisht  on 
tlie  absolute  functional  capai  ilv  of  cadi  organ. 

The  phthalein  test  in  assoi'iation  with  ureteral  eathetiTizMi  inn  ha^; 
iieen  used  in  seventy-five  cases  of  nnilalcral  or  bilateral  disease  f 'I'ahle  11). 
the  technic  being  as  follows.  In  most  of  these  the  -tibcutaneous  adminis- 
tration was  U-'  (1.     Kerentlv.  however,  the  intravenou-:  methoil  of  admini«- 


i.M-.i.!:  11    -i'iiTiiAi,i:i\ '>i  i  11  1  IN  t\vi;ntvsix 


Niiliilw^r  of  rin''     ! 

an<i  Name  ol'        j 

I'nticni.  ! 


niiiKK' 


4:t-  Mrs.  1, 

44— i: 

45    -«.  K.  .. 

40    r  ..    , . 


I 


1(1 


i 


iiTutioi:     fc)r     right     urtioral 


rr<'vious 

striclun'. 
Tiibfri'Ulosis   ol'   bladdrr    and    loft   kiilii^'.v. 


II 

1!  Ill  |(P   ; 

11  111  111       laleuli  rijjlii   klilin'.v 

11  -U'  HI   i   TubirciilosU  nf  rlslil  klilmy 


u 

L':;  HI 

4T      i: 

IL' 

>;    111 

Is-Mi.     Z 

ij 
i:; 
i-j 

4  HI 
l!'l  III 
ir.  Ill 

7     HI 

4n--r 

'- 

III   111 

so    i:  M 

lu' 

H;    Hi 

51  — K 

I'j 

IV.    Ill 

82— n 

11.' 

1 

-•:  1" 
i:;   1 1 

s;i    i>r.  n       . . 

11' 

.111    Hi 

I 


II 
11 

1 1 


r.  Ill  1 1 

I     L'll     11 

1   jr.  1 1 


Total   ftinvtion  .' 

'rubi'rnilo.is  ol   bi>th  kidneys 

Tiilal  fiinctliin.      N.phrocromy  12/15,  H).. 

Kxrri'tlon  ol   roniiilnint:  kidney 

l-:.\ereiiun  of  renialniiiif  kidney 

UlMbi  uephralsia  :  pelvic  cap.   -'>  e,e 

Iji-rt  nepbroptosis  ;  pelvic  dilafati'.n  I**  c.c. 

(ak'iill   left  kidni'y;  one  ealeiiluu-  iinl.ro 
pelvic  .iiinetnre. 

I  ahiiloiis   p)elijnepl.rili-.   lel'l 
'riibercniiisls  left  kidney 

After  nephioctniny   function  of  remalnlDK 

kidnev. 
Sliuht     Infection     1' fl      kidney:     |>revloiis 

neplirolitholuliiy. 

Sli:;bt  pelvic  dilalation  ti'^tit  Nid'- 

Multiple  absrevsps  left  kidney;  [■onoriii' al 
'rnbercubnis  pyonephros!<i  rluht  '^Ide 

Hyperneitlironia    li'^lit   .I'ie 

Left  renal  calculus .  . 


11(1  II     .  .  .  . 

i-.l  Mrs    A 

111;  A 

fi.l-  II     ..     . 

«4-r 

f..-.— f.  K.  .  . 

nil    (1 

67     K    W     . 
68— r 

«tn    I :    


-•^  1 1 

:il  II 

4  II 
Ul  II 
In  II 
IS  11 

111  n 

L'f  I  1 1 

HI  II 

5  U 
1'!'  11 
111  II 


falcuhis    liin-er    end    left    ureler :    marked 
bydroiieplirosls. 


NepbroplO!.|s   left    side 

I'robable  double   pyelonepbrltls :  subacutp 

llnnrmons   bydronepbroses   of   left  kidney. 

mill  C.I . 
Ilouble    pvelonephritls.       I  No.    «!    calbeter 

used  on  left  side:  No.  S  on  right,  i 
Sllubt   Infection  of  liuhl   kidney;   po^^slble 
I        stone. 

i    Persistent   lislula   of  left    ureter  follosvlnj.' 
ureteral  Ittlmtoniv. 
NepUroiilosiM  Infi  side  and  hydronephrosis. 


Multiple  renal  cab  all.  rluht  side 

i   SIlKbt  pnbi  In  rk'bt  renai   -eglon  :  few  pus- 

I        cells  In  bladder  urine. 

i    I  Seeonil.   l.*»   minute  u 


'■•  I 

<••  I 

ij  I 

■•  I 


ll. 

c 

.?■■= 

* 

c    , 

z  t 

< 

I, 

1  ino.o 

+ 

11 

i;i5.n 

+ 

I-.  ::o 

17.1) 

+ 

K.    HI 

r.i.o 

+ 

I.. 

1711.0 

-t- 

It 

lOII.O 

+ 

L      w 

:i4.u 

+ 

U.   Ill 

55.1) 

70.0 

+ 

KiS.O 

S8.0 


I,.    Ill 
It.    11 


U 

u. 
I.. 
It. 


I.    > 

K. 

I.. 
It. 
I,. 
It. 
I.. 
It. 


I...    10 

It.     •; 
I.,  i:; 

It.    s 

U    40 

n.  H) 


'.  1 :; 
i;     15 

I.. 

It. 

I.,  none. 

It.    15 

I..    Ill 

i:  1.". 
I.  7 
i:      ■- 

I.  .".II 

II     Uil 

I,. 
It. 
I.. 
It. 

U  5.5 

II.  ... 
I.  5 
It.   II 

U  4..S 
It.  U.ft 


150.0 
1.10.0 

5:i.o 

.-iH.O 
17.5 
L»4.5 


(11.0 
Sti.O 
.50.0 
.5',).0 


oa.o 
lon.n 

700 
(J3..> 

125.1. 

•JIO.O 

:;40.o 


2(M1.0 
85. 0 
IHi.O 


l.'.O 


+ 
+ 

+ 
+ 
+ 
+ 


+ 
+ 


+ 


+ 
+ 
+ 

+ 
+ 
+ 


+ 

+ 
+ 


115.0 
125.0 


IHIO.O 
liO.O    t 

no.o  I 

L'4I)  II 

11 II 
11 II 


40.0 
108.0 

10  5 

14  II 
2111.0 
350.0 

85.0 

13.0 
».8   (15  mlD.) 
;i.8  (15  min.) 


•  I'ortv  two  cases  not  shown  In  Ihl-  table  will  be  found  In  pre 
t  Aild  reaction  Indbnted  by  plus;  alkaline,  hy  inlnus 


lASES  OF  SURGICAI^  DISEASES  OP  THE  KIDNEY* 


I  nnd  Mliros.opliiil 
h'indinys. 


Ii'iir 

War 

us  and  tiiberck'  liHcilU. 


Cl'Mr 

I  loudy  :  p«s  cells  and  cncfi  j 

I'lcar j 

riMir 

I'loiidy.  pale:  pus  colls  Tew  j 
tubiTcio  bacilli.  I 

sliihtl.v  cloudy  :  pus  cells  ;  I 

tubercle  bacilli. 
Sliihlly  cloudy:   pus  cells  ;  | 

tubercle  lincP.li. 


I 


I  I'tir 


-nr  :  negative 

.  .If :  negative 

I!     corpuscles :    no    pus 
.  'lis  or  bacteria. 

■  .-ir:  no  pus  cells  or  bac- 
iria. 

iiuily  :  pus  ;  bacilli. 

■  iiidy  :  ptis  :  bacilli. 


!I:t/v  :    cocci  :    no    pus    cells 

tiace  ulltuDitn. 

'I'  :ir :  no  nlbumin   

iliir 


Niiidy  :  pus  . . . 


.Mliumin    i 

I'tire :  pus 

iiinctlon  remaining  lildney  : 

■  ollectlon   1    lir..   Hi   niln. 

I  lenr 

Uloody 

lifd    itlood-corpuseles :    I'ew 

leukocytes. 

I'lear 

>  lear;  few  leultocytes 

I'li'ar 

TntHi    IllrtioU    witUoUt    Catll- 

eteri/atinn. 
t'l'iir.   no   pus  or    bacteria. 
t'tt-ar.    no   pus   or    bacteria. 

•  1'  itr  :  few  pus  cells 

"  i'-nr  ;   few   pus  cells 

Illeed     (old) 

e-';ii    

I';i'  leils  and  cocci 

I'lis  cells  and  cocci 

''letidy  ;  no  pus.  red  Itlood' 
'■iH'puscies  or  bacteria. 

I'ie<,  lincilil  and  cocci 

"'leuilv  ;  pus  cells 

'  I'ur.  pale 


eiir 

|<'|..iir 
I  clear 
I  I  ■li'.i  r 


I  CI., -If 
Ci.;ir 

Icle.Tr 


h 


21.0 

17.0 

;;.o 

:i4.o 

15.0 

:ji).o 
sti.i) 
ivc 

I'l.O 
20.0 

tii.o 

.TS.ll 

•M.r, 
no.o 
is.o 
in.2 

15.2 

lit.'j 

28.0 


:to.() 
■13.0 

20.0 

:!i;.(i 

2(1.0 

2r>.o 

12.3 
40.0 
10.0 

0.0 


44.0 

Trace. 

iri.o 

27.0 

1.0 

21.0 
."i"  () 

l.'i.O 
IS.O 
14.0 
1-2 
0.0 

3:j.n 

ri.2 

0.1 1 
27.0 

21.0 
1.0 
27.0 
Trace. 
IR.O 
15.8 
12.8 
60.0 

no 

23.0 
22.0 
11.0 
10.7 


r.0.0 
21.-1 
10.0 
32.0 

ri7.o 

(iX.d 
O.s.d 
44.0 


no.n 

5.1.0 


45.0 
22..-. 
til.O 
84.8 
31..-. 

C8.0 

30.0 
8(i.(l 
20.0 
70.8 


42.0 
OS  1 


100.0 


04.8 

2.8 

21.0 


OOO 

32  (• 


20.0 

108.0 

13.0 

20.0 

100.0 

100.3 


8.0 
13.0 


Left     collected     tr((rsveslc:(l  :     ll..phl'iti)liiy  ;     IjMtl'y     diseased 

kldncv  ;  recovery, 
Ne]>li:ipluTuy  :     lower     nlie-tbifd     kidney     lilleil     with     calculi. 

(jplier  twu-tliirds  nortnai :  ri'covei-y. 
Xi'lihrectomv    12  5- Id:    recovery:    12  7   I".    :;2   iier  cent,   ei- 

eret.il  one  kidney  one  hour:  12  i:i  Id.  l'.s  per  cnt.  excreted 

one  kidney  DUe   hour:   12/20,  In.  .'d  pec  .  ..nt,  excreted  one 

khiney  one  lio((r, 
Ijcaka^e   of   27   c.o.    with   0   per   cnf.    urea   and   :'.    per  cent. 

plttlialel'i.   [.robiibly   fioin    l.ft.    as   sniall   catheter   used   on 

this  si.ie  :  [[ephceeiuKiy.  [i;;lit  side:  re.  overy  ;  kidney  badly 

diseased. 

Suspension  :  cute. 
Suspension  :  cure. 
Neplirolithotoniy  :  c([re. 

Nepllle,  Iniiiy  ;   ree.ivery. 

Xephr. ciotuy  :  recovery:  I. .ft  collection  trtiiisv. -.ileal. 


No  opefallon. 

Suspension, 

Xephrertoniy  :  C'cnvei  y 

Nephre.  toTuy  :   re. ncry  ;   left  .  .lU.'.'leil  traif-vesical. 


Neplitc.  t.tKiy  :    .l.'iith.    fimrlh    diiy.    fi.un    li.'Umrrhair''  :    slL-lit 

traces  .if  I  iL'ht   ki.in.-y  .inly,  altti.i^t  cridr.lv   te'.iplnst  i.-. 
Nepbfolith.'t.'tii.c  :  cufi'. 


ltein..V)(I  of  .al.'iiliis;  rpcov.r\. 


No  ..p.iati.ui, 

Nephrecttimy.  liKht  si.l.'  :  .  .inyenlial  atrophy  kldne\'  witli  dif- 
fuse cortliai  Infection  :  death  sixth  day.  fnun  pn.'uiuouia, 
Xephrectoniy  ;  hir:.-.-,  thln-walie.l  sac  ren(OV.'(l. 

Ijeak((ce    21it    .■  .',    I  ,-    per    cent,    urea    ami    Id, 'J    per    cat, 
phi  hah  In  l.nkaL'.-  from  left  sidi'  iiroljahly. 


N'ephre.  t.'niy  :    re.  ..very  ;    kt.iney    sh.iw.  d    s.v< fe    <>!.!    (tyeio- 
neplii  ills 


Total  funilioii  ne,.jt  .lay  Kith.iut  .,ith.li'i>,    I.".  i>.'r  ..nl. 
4.-.  per  cent,  for  one  lialf  hour 
Kidneys  are  appnnnlly  ii..rnial. 


41 


I  ration  lui.<  iiceii  omphmd.  wlicifliy  tliu  tinio  iicic>sitaleil  for  ubservation 
lias  been  reduced  to  half  an  hour,  collections  bein-  iiukIc  at  titleen-minute 
interval?.  Where  it  is  desirable  to  determine  whether  iho  suppusedlv 
healthy  kidney  can  as>unie  suilicient  function  to  prniit  of  tlie  removal 
of  the  other  kidney,  only  a  half-hour  period  of  observation  i-  necessary. 
For  the  particular>  ( oncernin.;:  the  technic  of  application  of  the  test 
in  association  with  ureteral  catheierization.  see  our  orip:inal  publication.^ 

ni:sri.Ts   obtainkd   with    riii:    imitii  m.f.in   tkst   in    nxn,\Ti:n\i.    wn 

nil.  MKKAI.    IMSICASI.    or    Till-:     KIDM-.Y 

In  normal  ia>es  the  tinu-  of  the  a|ipeaiami'  of  the  drug  Invn  the  two 
sides  has  been  almost  always  the  same  and  in  the  iiuijority  of  cases  this 
has  been  live  to  ten  minutes  foUowinj:  subcutaneov.s  and  three  to  five 
minutes  following  intravenous  injection.  The  time  of  aiipearance,  of 
course,  will  vary  somewhat  with  the  I'ate  of  urinary  secretion.  Xormallv 
the  amount  excreted  by  each  kidney  will  be  practically  the  same. 

The  series  of  cases  studied  inchide  tuberculous  or  pyogenic  infection, 
unilateral  or  bilateral,  (aliuli.  !ivdrone|)lir  ■  '-.  hyperneuhiouiata.  .'t.-.f 

When  one  kidney  only  is  diseased,  the  .u-.o  of  the  appearance  of  the 
dru-r  i^  delayed  on  th.e  diseased  side  and  the  amount  excreted  is  not  only 
r.-latively  iiut  ubsoliitely  decreased.  'I'lie  amount  of  delay  in  the  time  of 
appearance  is  comparatively  of  little  value.  Reliance  i<  to  be  placed  only 
on  the  (piantity  excreted  during  a  period  of  on.'quarter.  onc-hnlF  or  one 
hour,  depending  on  the  method  of  administration. 

.Vlthough  in  the  majority  of  these  ca-^e^  of  unilateral  disea-"  the  com- 
bined output  is  equal  to  that  of  two  normal  kidneys,  the  greater  part  of 
the  excretion  i<  shown  to  be  performed  by  the  healthy  kidney.  In  propor- 
tion to  the  ilcerea-e  in  function  on  the  diseased  side,  a]iproximMtely  there 
i-;  a  proportionate  increase  in  the  function  on  the  healthy  side.  In  such 
i-a.'^es  following'  m  plireetomy  the  remaining  kidney  eliminate^,  after  the 
lapse  of  two  or  tlii'-e  week-,  an  amount  of  drug  which  is  normally  excreted 
l.v  two  healthy  kiduev.^.  In  all  cases  studied,  the  output  from  the  remain- 
in"  kidn.\v  has  been  greater  than  tin'  cnnihincd  output  from  the  two 
kidne\s  prior  to  operatic:\ 

While  the  total  urea  from  the  ■•onibined  urine  i-  no  true  iiiilev  of  tlir 
functional  activity  of  the  kidneys,  the  ( ompaiative  urea  output  from  each 
kidney  is  of  decided  value.  The  same  amount  of  urea  is  pre=ented  to 
each  kidnev  for  elimination,  and  therefore  it  is  possible  to  e-iimate  to 
some  extent  the  proyiortionate  amount  of  work  which  each  kidney  is 
performing  I'.arringer  has  pointed  out  that  when  the  output  from  one 
kidnfV  is  four  times  as  great  a^  that  from  the  other  it  i-^  safe  (o  leiiiove 


■i  TliP  (let.Til- 
(■"innniniontions. 

Or;r.  '^''-fi.  isri". 


(■oni'Pininir  iVnty  nv"  '  Uic^f  i-i-'-  ■<"■  .  ,iii-i.i.'i.'.l  in  in.'vi.ius 
Tr.  Am.  .\^-^ii  <i''ii  lii"  S,irL'«M>n-'.  lilll.  iin.l  .\nn.  d.  Mat.  <1. 
-„i,- 1    M.....1,     ini  1 


4u 


the  disca.-ed  kidney,  provided  tliut  tlie  urine  from  tlie  0|ipo.-ite  -ide  give? 
no  indieation  of  disease.  It  is  of  most  value  when  there  is  a  marked 
disproportion  from  the  two  sides.  'I'liis  test,  liftwever.  lias  its  failings,  as 
this  proportion  docs  not  ahvaj's  e.\ist.  Again,  the  uiea  determination 
indicates  only  the  relative  amount  of  \voi-k  that  each  kidney  i.s  perfnrniincr. 
and  as  the  e.\acl  amount  of  urea  jiresent  in  the  blood  is  not  known,  the 
te.st  shows  only  the  relative  artivity  of  each  kidnov  and  'uit  tlieir  absolute 
functional  activity. 

Again,  it  affords  no  indiiatioi,  as  lo  whetlier  the  kidney  i>  woi'king 
at  its  ordinary  capacity,  or  as  to  whether  the  reserve  force  is  called  on 
and  the  kidney  is  working  at  it-  maxiTTiui,  .  and  therefore  nnnlile  tn  with- 
stand any  additional  strain. 

The  inef!iciency  of  these  metliods  ha-  neeessitatfKl  the  introduction 
of  tlie  more  recent  methods  of  estimating  the  functional  ability. 

A  striking  parallelism  exists  between  the  relative  amounts  of  plithalein 
excreted  and  tlie  relative  urea  output  for  any  period,  but  the  plithalein 
has  an  additional  advantage  inasmuch  as  it  indicates  not  only  the  relative 
e.xcreting  capacity  of  the  t\\(i  kidneys,  but  fnrnislii>-  an  approximate  idea 
of  the  absolute  ca]iacity  of  each  kidney. 

In  all  seventy-five  cases  of  unilateral  oi'  liilater;il  renal  disease  have 
been  studied  in  coiijuni  tinn  with  urctcr.il  catheterization,  the  series  com- 
prising cases  of  renal  calculi,  renal  tuhen  ulosis,  non-tuberculous  infection, 
hypernephroniata,  liydroneplirosis  and  nephroptosis,  ureteral  calculi,  ure- 
tei'al  strictiii'i'^.  luMualnria.  m-e-;  of  polvcy^tic  !<iiliio\  aivl  a  few  luiscp'- 
laneous  cases. 

Tn  bilateral  disease  it  has  liccn  found  po-silile  to  determine  the  indi- 
vidual function  (absolute  or  relative)  of  each  kidney.  It  i-  in  this  class 
of  cases  particularly  that  the  -Ijortconiing';  of  other  fiuK  tiona!  tests  have 
been  mo-t  appaicnt.  as  one  kidnev  luav  be  doing  twiie  or  three  times  tlie 
amount  of  work  of  the  opposite  kidiuv  anil  still  be  unable  to  a^^une^  ih'^ 
additional  work  of  the  other  kiilney.  It  may  he  doing  the  major  part  of 
the  work  at  the  expiMi-^e  of  all  or  nearlv  all  of  its  reserve  power,  but  tlio 
plithalein  test  determine-;  whether  the  kidney  hns  a  fiiiietiotial  i  apacitv 
which  is  normal,  less  than  or  greater  than  normal  and  to  wliat  decrree. 
Ill  two  cases  of  double  renal  liiberculosis  in  whieh  tin'  auionnt  of  pus 
from  each  side  was  practically  the  same,  the  test  permitted  it  to  be  deter- 
mined that  in  each  instance  one  kidney  had  a  function  greativ  in  excess 
of  the  otlicT,  indeed  sufficient  functional  capacity  to  allow  of  sui'cessful 
nephrectomy,  marked  improvement  in  ireneral  condition  (Kcuirir.'j  subse- 
quently in  each  case. 

The  details  of  one  of  these  cases  are  worthy  of  report : 

n..  iiijc'i!  n.".  .tliiiitto.l  Doc.  f.  iniO.  ('(miiiliiiniiii.'  ef  |iyiiii;i  :nvl  -1)1110  f.iilurc 
in    ''cnoral    Iicilth. 


4»i 


(y.-toscopie  cNiiiiiiiialiuM  icvoalod  ii   niniii.il  lil;i 
tlie   following'   liliilin;.': 


l.lcr.     S>'|.ai;itfil  iniiu'"  yielded 


r.eft 
ins  e.c. 
t  luiidy 
I 'us  cell- 
Inliercle    liacilli 
Alliiiiniu   + 
Ilea  <M)  0'_'. 

I'litlialeiii  ajipearwl   in  s  niin. 
■it)  per  cent.  lor  one  liour 


KiL'tll 


SS  c.e. 
(  loiuly 
I'lls  eidls 

Tiilierelo  liaeilli 
Alliuniin  + 
flea  35  e^'. 

Time  of  appearanee  S  niin. 

1-J  per  cent   plitlialeiu 


l.caka^'e  of  27  c.c. — :!  per  ecnt.  plitlialein  and   14  e-.'.  ot  una. 

.\ltlioni;li  (liva>("  existed  on  both  sides  ami  Iroin  the  liiaraeler  of  llie  urine 
it  was  inipossildc  to  determine  wliicli  side  was  more  badly  .li-eased,  the  idithalem 
indicate,  that  the  left  kidney.  althoUf-h  diseased,  had  the  function  ..f  a  normal 
Uidnev.  The  rijzht  kiUnev  in  this  ea.se  was  evhlcntly  the  prinnuy  seat  of  disease. 
Nephrectomy  of  rij;lit  kidney  was  successfully  undertaken,  hein-  followed  hy  a 
marked   improvement   in   the   patient's   fieneral   condition. 

The  function  of  the  left  kidney  s'a'li'aH.v  increased  iinlil  the  output  at  the 
end  of  three  weeks  was  30  per  cent.,  opial  to  that  <u"  tw.i  normal  Uiilne>-.  Ij-.e 
kidney  removed  was  liadly  diseased. 

It  si'oin-  ].n)liabk'  that  in  tlii.s  iiist.'  tlio  infection  was  liniited  to  a 
localized  area  and  tluit  the  jircater  part  of  the  kidney  was  hfaltliv  and 
gub>eqiientiv  was  able  to  underfro  ponipensatory  hypertropliv. 

In  a  case  of  bilateral  pvonephrosiii  due  to  calctdu;=.  .striking  coi'.liiina- 
tion  of  the  accuracy  of  the  Ihulings  of  th;'  tc-t  «ns  atr-ivdod  by  th.e  follow 
ine  case : 

1'.  K..  a'.'cd  ST.  admi'ied  -Kni.  1.  l!Ul.  uiih  vomiting'  ami  pain  in  epi-astriuni. 
Oiajinosis:  douhle  renal  calculi  and  iiyonephrosis.  uremia.  In  HI03  patient  had 
ri'jht  renal  colic  for  first  lime.  f(dlowin<r  wliich  he  passed  two  stones.  Since 
then  he  had  had  iwo  similar  attacks  on  the  left  side.  For  last  three  months 
he  has  had  fre.pient  attacks  of  pain  on  the  left  -hie.  dyspnea,  vertifio  anJ  vomit- 

On  ■•\amination  patient  was  fouml  markediv  emaciated,  hemo-lohiu  .')0  i)er 
cent.;  red  Idood  corpuscles  ;i.30IJ.00O:  white  Idood  cells  !S.5()0.  Khlneys  not 
|)alpahle;  no  tenderness.  .V-ray  showed  stones  in  lioth  kidneys  and  in  upper  pnr 
tion  of  left  ureter.  Urine:  1700  c.e.  in  twenty-four  hours,  specific  L'ravily  MIT. 
alliumin   +   +  ami  cloudy  from  pus. 

riithalein  test  .Taiuiary  '.'.  no  ilrii';  for  two  hours.  Under  forced  water  the 
urinarv  output  increased' and  patient  hecame  less  to\ic.  nausea  and  vomitinj: 
di-app'earinj.'.  Plithalein  output  was  now  3  per  cent.  Two  days  later  uremic 
symi>t<.ms  reappeared  and  the  plithalein  output  was  a^ain  ?ero.  .\  doulile  neph- 
rotoniv  under  fias  was  rapidly  done  in  the  hope  that  some  relief  might  be  thus 
secured.  Hotli  kidnevs  were  found  to  he  merely  thin-walled  sacs  filled  \yith 
calculi  and  |.i:s.  Patient  died  in  uremi.-  ,  ..nvul-ioii-  in  less  than  twenty-four 
hour-. 

'I'll.-  e\i-tciui'  of  an  iiil'niitile  kidney  may  lie  readily  overbioked  ina?- 
iniieh  as  under  rinnnal  lonilitiuns  ilie  urine  from  sueii  a  kidney  may  b.- 
nbsoltitcly  normal  so  far  as  color,  specific  gravity  and  urea  percentage 
are  concerned.  The  literature  abounds  witli  ntuneron?  report=  of  death 
f__„,  -pri-'.l  fiidure  fidlowin"  nenhre: tome 


,1no  tn  the  innliilitv  fo  recorrnize 


the  prejciitf  nl  an  infantile  kiilne}.  Iffn-ntly,  Kuniiin'l''  and  M.  Anliiir^"' 
have  eaeli  reported  deatli?  followiiic;  neplirectoiny  wliere  an  inranli'i'  kid- 
ney had  hien  left  to  assume  the  work.  In  our  series, two  such  kidneys, 
the  seat  of  disease,  have  been  removed,  am!  in  a  tliird  rase  with  hladiler 
tuberculosis  and  suspected  renal  tuljeic  ulosis  without  Inralizini:  -yniptoni-i 
on  either  side,  an  exploration  of  the  left  kidney  levealed  a  healthy  hut 
infantile  kidney.  Mxploiation  was  n'?eessary  inasiuueh  as  t!ic  bladdei- 
was  markedly  contraeted  and  it  was  found  impossible  to  eathoterize  the 
ureters.  ,\  similar  condition  was  encountered  in  a  eat  utilized  in  onv 
experimental  work  (described  below). 

The  details  of  one  of  these  cases  is  presented: 

t  ..  ailtnittiil  .\liirrli  I!'.  IttlO.  ■I'liljoiTiilosis  in  an  infantile  kidney.  Tlii'  left 
ureter  wii-  oatlieteri/od  Imt  on  aiTount  of  ulceration  of  the  ri^'lil  iiretoriil  orifiei' 
it  wan  found  impossible  to  eatlierize  this  ureter,  the  urine  from  this  side  tlieicfon 
beins;  colleeted  trnnsvesieally.     'J he  «eparatiil   urine-;  were  as  follmvs: 


f,..ft 
40  e.c. 
(tear 
Normal 
.\ei<l 

Specific  jjravit.v    lOJd 
Irea   28   l)er  rent, 
lotal  urea  Hi  <■;;. 
I'lithalein    appeared    li   niin. 
riithalein   excreted   44.4   jier   cent. 


llifjlil 
•20  c.c. 

Slightly  cloudy 
Some  pus  cells,   no  haiiciia 
.Acid 

Specific  jiravify    lOlii 
Urea   IS  per  cent. 
Total  urea  34  "l'. 
I'hthalein  appealed  IS  iiiin. 
I   per  cent,  excretion. 


The  rifilit  kidney   \va-  removed  and   wa.'    found   to   weiyh  40  jrm.      'I  lie   upper 
two-fifths  were  destroyed  hv  tuhereulosis. 


When  the  disease  is  present  in  the  Iari:e  kidney  nothinjr  -hort  of 
functional  test  will  reveal  the  presence  of  tlie  infantile  kidnev. 

Tn  certain  cases,  owinsr  to  malformation  or  strictures  in  the  lower 
end  of  the  ureters,  and  especially  in  bladder  tuberculosis,  it  niav  he 
possible  to  catheterize  one  ureter  only.  Wher.  infection  of  the  bladder 
exists,  microscopical  and  chemical  examination  of  the  uriu"  collected 
transvesically  is  obviously  unreliable  as  an  indication  of  a  henlthv  or  n 
diseased  condition  of  the  uncatheterizcd  side.  It  is  therefore  necessarv 
to  resort  to  estimaiiioi  of  functional  capacity  in  order  to  deforinine  the 
presence  oi-  absence  of  disease  on  the  side  not  catheterized. 

Tn  many  iie^tanees  of  tuberculosis,  as  in  the  following  case,  it  is  the 
healthv  kidney  wldeh  can  he  eatheterized  and  the  absolute  evidence  of 
disease  on  the  other  side  in  the  presence  of  an  infected  bladder  must  be 
ascertained,  not  by  microscopical  examination  r.f  fbe  urine  hut  bv  func- 
tional capacity. 

Diayno'ii^:  Tuhercuiosis  of  rijiht  kidney  und  -ni'-fnte  nf  lower  eiid  t-f  ureter. 
I'atient  admitted  with  history  of  attack-  of  ]iniii   in  tlie  right  kidney  region  and 


:!7.   KiiniiMd:   .Tour.  Sursr..  Cxn.  and  Oh-t..   .\pril.   I!UI. 
.'tS     Mp\!flinr-    .Tnnr     Surer      Cvn     iiiid    Oti-t        \iiril      Hill 


48 


an  liitcinutt.'nt   py,.  ..i,      A  skia,i;riuii   ua^  iH-iiliv.    ilii'  1,1,1.1. l,-i    iniiif   wa>  cl.:.-r 
ipically    ciiitaiiicl    a    few     leukueUt-.     ii.i     iirgaiii-iii>.        (  y.,to.,CO|)y 
The   left   ureter    was    readily    catlicterize.l    but    an 


but    niiiTO-eopi 

revealed    a    nornuil    libuMer 


revealed    ;i    ii.Jiiiiai    inaii-nri.       i  "^    l\^y^    ...w..     ....-     .■     - 

obstruction  at  the  lower  end  of  the  rigbt   ureter  obstructed  the  catlieter  ..u  this 


side,  necessitating-  transvesical  collection.     The  separated  urines  were 

Ki-hl 


as  f.illow- 


Left 
45  CO. 
Aci.l 
I  lear 

Specific  firavity  H.Jt 
I'rea    05    ej;. 
I'lithalein  appear.'.!   in 
:!:'  per  cent  exciit.'.l 


7(1  e.c. 

I  I.Mr 


linii 


I'.'w  liiii.iieyt.'S 
\ I.  (irnaiii-nis 
A. -1.1 
iiin.  Spocillc    j.Mavit\ 

I'rea  111  c^. 

rhthalein   appcar.'.l    in    -'<    "I'li. 
."i  per  I'. 'II'.  .'xcr.'li.ni 

On  account  of  tiie  I.jvv  function  and  tlie  presence  of  the  ur.l.'ial  stri.'lurc.  a 
probable  diafjuosi-  of  tuberculosis  of  tbe  rijiht  kidney  was  nade  an.l  a  nephrec 
tomy  p.'rforined.  tin  examination  tliis  Ui.lney  was  found  to  be  ba.ily  diseased. 
:illh'.'U'.:li    til.-   urine  contain. 'd    ni.   p;itli.il.i^i.  al    features. 

Ofcaoioiiallv  it  is  impossible  t.i  .  ntlit-tcnze  (itlicM'  uictcr.  |iartirul;irlv 
in  marked  v.-sical  ttiherctilusis.  Here  bv  tlie  aid  of  iiuli.iocarniin.  iintiii? 
the  time  of  the  a[ipearan(e  of  tiio  diniir  on  eaeli  side  and  from  tlu-  evidence 
obtaiiici!  from  < y.stoscopv  ami  from  localizing  clinical  symptoms,  it  will 
SCEcrallv  be  po.ssible  to  arrive  at  a  probable  dia?nosi=  as  to  which  ki.lnev 
is  involved.  The  total  function  as  determined  hv  m.aiis  of  phthalein 
will  determine  whether  the  di.«ease  is  unilateral  or  bilateral.  Wlien  one 
kidney  is  siisjiected  and  vet  a  crnnd  total  iviial  fi'.mtion  has  lieon  indicated, 
this  side  can  be  explon.l  an.l  if  f..inul  to  pu -out  cvi.lcn.i'  .if  ]>iaiki'd 
disease  can  be  removed  with  safety  without  exploration  on  the  oppo-jte 
side.  Obviously  exi-retion  of  a  larfie  amount  of  phthalein  must  have  been 
performed  by  the  opposite  kidney.     Such  a  case  is  here  recorded  : 

The  patient  bad  marked  vesical  -ytn|.loni-  aiul  pvnvi;.  uilli  tubercle  bacilli 
in  the  \irine.  On  cvstoseopie  cxaminntioii  the  wbol.-  tri(;..iie  vva-  bailly  inllanied 
an.l  p.|emntou-.  Tlie  risilit  ureteral  oritiee  wa«  badly  uberated  an.l  could  not 
be  catlieteri/e.l.  An  attempt  to  catheteriye  the  !eft  side  also  failed  on  account 
..f  lhi>  e<lem.'.foui  con.lition  of  the  mucoid  ni.'nibrane  and  the  contracted  eou'lilion 
..f  the  blaililer.  This  eytoscopic  picture  of  the  ri^'bt  nnteral  orifice  indicnte.l 
probnble  disease  of  Ibis  kidney  but  (lisea<e  of  the  oppo-iite  side.  also,  could  n..' 
lie  excliicied.  .\  plilbabin  test  for  total  function  '■liovve.l  an  excretion  ..f  •t.'i  per 
cent,  (or  one  b.iur.  A  rifht  sided  exploration  reveali'.l  an  a.lvanced  tuberculosis 
of  this  kidney  and  a  nepbrect.iniy  was  perform..!  wlthoiil  exploration  of  the 
other  side,  which  must  have  been  respon-<ible  for  the  ;»o(h|  r.'iial  function  in.lie.ile.l 
by  the  test.     The  recovery  wn«  uneventful. 

.\  patient,  showing  riiihtsi.led  intermittent  liennituria  an.l  chronic  nephritis, 
a.lmittrd  .'>ept.  1!>.  IttlO.  had  ureter"  entbeteri?ed  anil  the  separated  uritien  yielded 
the  follow  ing  data 

Left  lliKl't 

n..')  o.c  I"  <■'<•• 

Aeid  •l™'" 

MIoodv  Arid 

fren    IH  c'  21    rf.   ur.'a 

Phthalein   11  min.  AppeHreil  11  mm 

II  per  cent,  exoreteil  II  r-'f  '"''"    exereted 


l'.» 


f 


'I  iiu  following'  il.i.v  tiiliil  tiiTiclioii  without  oatiicteri/.itioii  wus  sludii'il.  iiuiput 
he'tni:  2\l  per  cent.  'Ilie  cqtuU  and  decreased  function  us  indieatnl  bv  tlu>  plithalein 
allowed  a  bilateral  renal  di«en«e  due  to  clironic  ncphriti*.  A  tew  ca-^ts  were 
I'i'iiiid   in   tile  luinf. 

Till'  value  of  tlip  plitlialoiii  output  over  thnt  of  urea  is  ptrikin<;ly 
lit  nioiistrntcil  in  tl'.c  ciisi'  Just  cited,  eliniination  lifinsr  practically  equal 
for  t!ic  tun  -ill,  -.  Iiiit  iin  imliialinn  was  afTonlril  of  the  redueeil  total  renal 
funi'lioii, 

Tn  two  out  of  thiee  rases  witli  In'peini'jilivoiiia  a  deiica-e  in  fiiiirtion 
was  inilirateil.  In  tlie  tliinl  fa-e  tio  dilTerenie  in  function  for  the  two 
sides  was  inlii  ated.  Tlie  phthalein.  the  urea,  specitie  prax  ity  and  quantity 
of  urine  colleitcd  from  each  side  were  identical  and  nonual.  On  account 
of  pain  dm  lo  a  slight  livdronephrosis.  the  kidnev  w.is  explored  ;  ;id  the 
lunioi-  di-iovercii.  The  hvpetnephroiiia  had  not  invaded  the  kidni'V  hut 
wa=  ^!ruply  altr.rhed  to  its  upper  polo,  in  all  lik'elibnod  not  'nterferinsr 
at   all   \\ith   renal   function. 

The  test  ha-  lui  ti  u-ed  li\-  \i<  <iinullaiiei-i\is!\  with  'V-toscot  v.  phlorid- 
:'in.  indijroearmin  and  ilie  ]iol\uiia  te-t  of  Alharran,  \o  particular 
at'vi'.ntairc  was  added  hy  conil)inin<r  with  one  or  all.  Iiidis-ocarniin  and 
phonolsulplioniphtlialcin  can  he  comhined  as  fnlinw-,  I'nliowiner  the 
appeiirance  of  phthalein  after  itijeilion.  ."i  e.r.  of  t  per  cent,  indiirocarniin 
susjiension  is  iiije(  ted  into  the  jilllteal  niu-cle<  and  tlu'  tisne  of  appearance 
in  the  acid  \irine  noted.  While  the  amount  of  phthalein  e-i  I'efed  can  be 
Pi'tiiratcd  vvith  a  fair  d cirri  e  of  accuvacv  in  the  pre-enic  nf  itidiij-ocarmin 
hv  reiideriicj-  the  nrine  alkaline  and  hoilinir.  on  the  other  hand  the  amount 
of  indi'jocannin  excreted  can  lie  est'inatcd  after  acidifvin;:  with  hvdrn- 
chloric  ai  id  or  ^ldphuric  acid  at  the  he^t  oti'v  romjlih  .  and  occasionallv 
not  at  all.  When  the  twn  tests  arc  u-ed  -iniultancon-l\  the  whole 
te-i  i-  I  omjilicated  with  the  introduction  uf  no  adxantaue-  and  -onie 
disailvanta^'i'-. 

In  ilie  fiaiowin;.'  ca-e.  witli  a  painful  kidni'V.  with  eld  bcaleil  p- elonepliritis. 
\ariiMi-i  fiinctinnnl  ti"it«  were  ronibined,  urea.  pMorid/in,  cryes.^opy  an<l   polytiria. 

left  Iti^lit 

.•C.'S  c  e,  80  c.c. 

Speeilie   cravily    10111  Specific  ;.'iavil\    lOOd 

frea  40. (t  cc.  I'rea  H  cf. 

I'litbaliin   appeaicil    7  itiin  Pbtlinlcin   appcaidl    S   t.iin 

I"\i'reliiiii   'J.'i   per   cent  fur   1    In.  Kxercti  .n  S.8  per  cent. 

I'lilorid/in  te-t.   iiiiccted  !i   uii;.     Si^far  iippearcii  in   1  .*i  mill       Trnce   in  ^.1   niin 
iiti'^:    1.9.")  L'"'     in   I    Iiciir. 

( ■ryo''C"p.\ .  mine  fo-  llrnl   l'O  minute-       1 1   c.c  A      -0  00       j,>i      Oir) 
I'nlvii.ia   fe-l  ■ 


Left 
■»4    re. 
U'O   cc. 
ir,'-.    ce 
tritii Heeled    in    L'O  niintit.-   nenoiU. 


Riplit 
•22  c  c. 
■22  e.r. 
41    c  c 


5<i 


iMiiiuiiox  (IF  rr.Ni  TiiiN  AS  i!!!:  K;;.-;ri.r  of  crki'kual 
c.uiii;r!:i!iZATioN 
A-  [Hiiiili'tl  oi,!  Iiv  Iviiisamincr."'  :i  (Ikhil"'  in  l\iiution  of  tlin  kidnev 
somoiinic-  it'?ult.<  fri'iii  tlic  'itiodiu'iioii  of  ilic  ureteral  ciitiiptei?  and  niav 
(HI  ii-iiinally  ?eriou.-l_v  imril'crc  with  tlie  \a!iie  of  (luantitative  detorniina- 
tion^  of  ilic  I'ciial  fiinctioM.  Follov:in<r  catlictrrization  anuria  i-  mcit 
fn^iui'iit  but  seiuplinit't:  |iolyn!ia  oicnrs  and  (ncu  in  tlu?  jirL'Sdue  of  poly- 
uria in!iii)ition  of  ^eoretilipr  fiiiictKiM,  urea,  el''.,  nmy  he  pre?t'l)t.  In  mir 
scries  a  n'.odi'rMK'  !:radc  of  i:iliibition  has  uocn  noted  in  six  cases  out  of 
seventy.  Tliis  irdnhitory  influenee  of  tlic  catheters  can  be  readily  detected 
by  deteiniiniii:;'  the  total  fniiition  uitliout  the  use  of  tatheters  uiiirh 
should  always  1  c  done  as  a  control.  In  nn  instance  in  our  series  was  the 
inhibition  of  such  a  trrade  as  to  interfere  seriously  with  the  value  of  the 
te>t.  'I'liis  inhil.'.tion  of  function  liiiiu  urctii-  (aJictci-  has  al-n  been 
noted  by  Keyes.  Jr..  and  A.  K.  fetevens.'"  The  MKi>t  serious  disturbance 
in  our  e\perienei'  occurs  slinrtly  after  the  intro(iuction  of  the  catheters 
ami  it  is  wise  to  wait  until  the  eatlieters  are  workiujr  frwiy  and  snmothlv 
before  jrivinp:  the  ]ilitlialein  injection.  If  tliis  tec-hnie  is  followed,  inhi- 
bition will  probably  not  play  an  important  rfdc  in  the  crei";'  mnjority 
of  cases. 

ni;\"AL    KUM  riON     lilFOlIi;     and    AITKU     NKI'IIDF.CTOMV 

'I  bis  problens  bus  been  investijjated  from  the  experimental  and  from 
ti.o  clinical  side.  The  cats  employed  in  the  diureti(  work  (referred  to 
above)  were  utilized  also  for  the  •itudy  of  this  problem.  Hurinsr  the 
course  of  active  secretion  one  kidrnv  wa-  suddenly  tied  off,  the  .|iianti- 
tative  secretion  of  urine  and  phthalein  bein?  subse(]uently  studied  and 
foniiiared  with  the  excretion  prior  to  this  nephrectomy,  the  condition-  of 
the  experiment  of  course  bein<r  kept  absolutely  the  same  after  tiie  removal 
of  the  one  kidney.  In  the  majority  of  instances  a  -litrbt  fall  both  in  tlie 
quantitv  of  urine  and  in  the  phthalein  excretion  (Hcurrcd  iinm(^(l lately 
after  tyinff  ofT  the  one  kidnev  :  oecasi(iuall\  the  plithalriu  remained  the 
same  for  one.(jiiartcr  or  one-liaif  hour  and  then  L'radually  fell,  and  in 
one  instance  the  itrinnr\'  flow  was  increa-ed  while  the  phthalein  output 
renuiini'd  |piai  licalK  the  same. 

One  (ase  is  of  particular  interest  inasmudi  as  the  removal  of  one 
kidnev  srrratly  rrduc(>d  the  urinary  flow  and  at  the  satne  time  reduced 
the  (>titlial  in  "ufjiut  to  one-tifth  of  its  former  level.  Thi--  fiudinjr  was 
unique.  In  this  (ase,  however,  it  was  feund  that  the  remaininii  kidnev 
was  concenitallv  atrophic  or  infaiiti'e  ;u  rliara(ler  and  wei'jhe*!  onlv 
fi  )  ■_'iit,.  while  tile  kidtici  wliiih  had  I.e. n  icine\rd  «' iehed  '.'I'l.  I  'jin.  ThiJ 
is  11  strikuiL'  exaiup''  nf  ih,.  value  ef  the  |e.  i  iti  dcteeiJMi:  the  ti-tie  func- 
tional cjipacity  of  a  kidpev 


.IB.  Kap'ttmnii-r :    Sr.'  "iieeiiit    |i:ii"'r     lli'f,  'i. 
40    Ki'\"-i-    IVfioniil    reiMiiniiic.ilien 


^j 


51 


The  fiinctioii  of  the  two  kmur}<  mi  tlic  (hi\  ol'  the  operation  hu.-  heell 
estimated  and  toiii;>aivi]  with  tiie  ruiutioii  of  the  leinaining  kidiiev  us  it 
is  on  the  day  i'ollowing  operation.  Cliart  J 4  shows  the  curve  of  excretion 
prior  to  and  the  da\  fuilnwiiiL;  iiephieitoiny  in  a  dog.  the  estimations 
being  made  at  livp-niinute  intervals  after  tlu-  appearance  of  the  dru?  in 
the  urine  follnwing  an  intia\rnoiis  injection  of  0  mg.  of  phthalein. 
Alllioiigii  the  rate  of  ..m  i.  noii  i-  <oiiiewliiit  >hiwi'r,  no  great  deciease  in 
function  IS  indii-.-ii  d  at  ihi  .  mi  ,,i  a  half-hoiii'">  (ih-eivation. 


'  li-iii    )  I.   ■   I  111'  iii>prr  Mil.'  ri'iir.'siMit^  tli.'  plifliiil.Mii  cMTotinii  f.ir   .-u-  li.ilf  Imiir 

liilliiwiiiC  iiilrini'iiriii*  injivtidii    I  h.'  i -tirnnl  inn-  ]„■;,,._,  ,ii,ii|.'  mi    (he  iciiiirir.  int-i 

vnN.      Ihc   Ic.u.'i    line   r.'|in-cMt-   th ,...(i,.ri    ni   i!„  ..,„,.■  ,1,,-   Im,    ...n-   li-lii'v 

within  HviTity  fnin    lidtir*  iifii'i    ri|iliiiriniin 

in  tho-e,a-f>  m  \v|,i,  |,  il,,.  fi.n,  ilnii  o|  ||,r  irniainiiig  iicalliiy  kidney 
wa>  e^tinlated  af'.  r  an  int.  rv:il  i.f  thve  we.k>  lo  one  month  follnwine 
nephiectomv.  the  fiim  Ikhi  w:i-  iiuariah'\  r..iin(l  ikiI  merely  lo  e(|iial  thi- 
■  nmhined  fun,  tion  of  the  iIi^m-,  d  ami  heatlhv  l,idnev  prior  to  r.prrat inn. 
iiilt  to  h.'  lU'linit'MV  .jr.  all  1,  In  a  'rw  ,:\-~  m  whlih  th.'  fur.  |i..n  ua- 
oHtitnati.d  af  an  interval  of  a  few  ,\:i\<  I.,  a  week  following  neplire.-tonn  . 
ttir  lumtioii  coi  re-pond-  wyy  cJo-Lly  to  lii..t  whieh  existed  in  il'at  kidiiev 
previdii-  lo  np,iati..ii.  I.ni  at  the  rnd  of  a  period  of  tliree  week-  ,r  a  mnnth 
the  fun'tion  wa*  a!wa\s  ecpial  to  that  of  (wo  normal  kiilne\-. 

In  one  case  of  doiilile  n^nal  tnhen  uiosi-  in  wlii.li  the  fmidion  of  the 
kidney  h^fl  hehin.i  wa-^  ■,'(;  per  .  .'mI.  for  one  liour  prior  lo  op.Tation.  if 
increased  until  at  the  cinl  of  one  month  a  phthalein  exerethm  of  '0  per 
i-ent.  for  one  hoer  was  attained,  whiih  wn-  ronsiderahlv  ereater  than  tlie 
lotiiliined  funi  ti.m  of  111,,  h,,,  kidnev- prior  (.)  operation      hi  thi-  in-tancp 


■lAiii.i:   ii.>.--At  riirsv 


1—1!..  UL'.-.I  •■:'.•. . . 
774U1 

1'--Ij..  apf'cl  4B..  .  . 
77,->4:t 

:!— G..  acod  71 .  .  . 
7.')74 1 

4 — T.,  aeed  :'..". . . 

772«S 
5 — McC.  ;itiotit  GO 


7      Mr«.    \V..    need 

L'l.     7:i74L' 
S—T.   r.  .  ni;.d  .".7. 


!l      I...   ns^ll  "li.  .  . 
SurK.  So.  -Ti.'.lO 


111  -<;..  naiod  .'..'. .  . 
Suri;.   X".  ■-•.-.174 


II      II    T  .  nu.'d  20, 

7iiiini 
IJ— O.,  need  12. 

774.W 


i:' 


11  !T.<d      4  1 


14      P..  Hii'rt   2!>. 
70710 

m— O  .  nsid  n.'!. 
10-  T  .  iiir.il  r.n 
17      !•  ,    hlvmI   77, 


Siiris.  No.  28Sn8 
10— I,.  »KPd  .-M    . 


20— r.  I.,  nsfd  no. 

202:111 
21— R..  aifid  m      . 
Burg,  Nn,  2.".ii:'.7 


Dal>' 


riiiiicnl  IM;i;.'liii.«ls 


:■.  2s  n 

.-1    2S  ■  1 1 
11     11    M 


:;  .■•,1  '111 
11     r,    M 

II    14  in 

11  n/10 

1    .".,'11 
1    7    11 

1  '!)     11 
1    1 1    1 1 

1    22 '10 

1  20    10 

2  4     1 1I 

12  22/00 
I  •  7     10 


AliHc"  crdoearditl--.  luitnil  ln-<iifflrii'nc.v  d.vsp- 
n«'a :  no  fd''iii:i  ;it  ilmo  of  li'st ;  di'veloppd 
laliT  ai'utt'  ni'pliriil^. 

.Xi'tiM-losi-lcrosis.  iioriic  in'siiftli'li'ncy.  acute 
f'lidooardilN.  dy^piHa.  sniin'  <  doraa  of  legs. 

.Xrterlosclero'fls.  hrt»ii'li'tpn*Minioni!i,  hyper- 
trophic arihrirl<  deformans;  hlood-pt'-ssure 

Chronic    osicnncHii^  ;    il.-vilofied    a    tnbercii- 

Iniis  pneiininnht. 
Ilypcrtropliy  prostiit'',   small  re-iidn.tl 

SyphiliiU'  ncpl'iitis-.  rdcma 

T'rcmic    

.\ansca  and  vomitlnir ;  hlsh-i:rad''  <  hok*'il  ili-k  ; 

si'vere  anemia  ;  d'-.inlte  iiri'miii. 

Rilaleral  caIcMloii«  pyoncphritis  :  uremia 

Some  Improvfiiient.  liot  so  much  nausea 

Improvinir    

Airain    seyer-'ly  uremic 

IlyP' Ttrophv  prostate,  larce  resl'^ual.  myocar- 

ditl-i.  some  dvspncn. 
Condition    seems    ln'tter:    has    i.ad    retention 

catliei.T. 
Condlllon  same     


!    Ill  '111 
1    20/11 


::  ::i  -11 
4  II'  11 


Midoscopi.iil    nndla^'s 


.il!i,  ait<l  occas.  cast 


.\'b. 


and  casts. 


Ilyperlrophv  of  prost.-ite.   larile    residual,  some 

'aneniia.  slitrlit  nausc.-i  and  vornitinii. 
Reteiiiion   ra'hrter:   condition   same;  up  and 
alMHit  ward;  urine  output.  2-ri  liters;    ireii. 
2.-i-."i)  cm. 

More  iiaiisi  ;i  and  vomitlnff  :  in.1ee.  .'to  mc 

Acute    pneniiinnla  ;    died   1 ''27/11.    of   abscess 

and  cancrcne  of  hint; 
niatieiis  Insipides  ,  linl.al  dia^'nosls;  no  siL'ns 
of  nephriiis. 

Same  eondilion    

Arteriosclerosis,    i  lir,    nephritis,    niyoeardltls. 
pericarditis,  edema,    dyspnea.    Von   tlraefe ; 
blood-TiresBiirp  11  n. 
1    20   II    I   Chr.  nephritis,  aortic  and  mlirni  Insulflcleney. 
I       i.'cn.  rai  anasarca,  dyspnee  ;  in  had  condition 
I       but  noi  iiieralc;  hlood. pressure  100 
1   2"  11    I    Hypernephroma  of  ri-lit  kidre-y 


7     7    111  i  Complete    i-.tenthm.    ihie    I.)    contraction    of 

I  vc'sic^al  nei'k  ;  chr    ahs.-ess  space  of  Rollins  : 

'  ond  cllni.  at  eonditlotj  ;  had  cystitis. 

12   HI   10   I   Uyricrtrnphy  of  prostate  ;  pyuria 

12  10/10   I   Some  fever.  drows\- 


2N    i-.c     of   urine   excreted 

i:i  Iwo  hours. 

All)       •  -  ;  few  casts. 

clear. 

Aii>.   -r  -r  :  casts. 

.\lli,   4-  :  no  casts. 

.\P»,  -  ;  cloudy  from  p'i~ 
Alb.  -:-  :  cloudy  from  pn- 
Alb.     -    ;  cloudy  from  pu-- 

Alb.    -•-    and  casts  ;   c!  r:i 

Aih,  -f  and  casts:  cloudy 

Trine    pale;    cioudv    freai 

pus. 

Tiioe  aih,.  sllirhtly  clou. I 

Horn  pus. 

Trine  more  1  huidy 

Cloudy. 


Nciintivc. 

\o  nih  or  casts. 
All.      .    .    :  f.'w  casi. 

Alb.  :ind  -h..K. 

Ill  I  asls, 

21"!  c  1'    from  rli:ht. 


0  '  7  /lO  I   Hypertrophy  of  prostate  ;  niToriirdttt* 

017/111   I   calhi  ter  clrnlnnL'c 

10    1   'in   '   Catle  h  r  dialnaee 

HI'  7  '10   I   Carclniucii  .if  pr.istale  ;  iivurin 

10/17/10    I  . 
10/21/10   I 

7   10.10   !   H\  p.Tfrnitiv    of    prostate;    acute    retention; 

I         uood  coliillllon. 
;!  2<'in      HyiHutrophy     of     prostate;     retr.iveslral     ah- 

sc'ess ;    septic    tenipiTatiire ;    fractur.-    hip; 

bad  shape. 


t^loiidy  :  ftiis  ;  .-mail 
amount  ulb 

I'us  and  aili 


.Mb.  -*-  ;  pus. 

Alb.  -f  ;  pus 

.\lb    -t-  ;  pus 

Alb,   + 


:i  '.ll  10 
4  12  10 
4/2.1'10 


V»ry  *lrk  :  suprapubic  drilniii)'. 


I'yurla 
ryurl«. 


•  l<rft  kldnp.T  rirretrd  44  per  frot.  In  1  hour  (Od  10  mlnntn;     rItM  IMMr  tracr. 


Al'.l.l:     l.'.       AIlill'S^ 


I'lrccnlasi-  "f  I'lnu 


riMi' 

Twij 

Huur. 

1I.H11>. 

:in..j 

ir.r, 


u<  I 


.■i:t.(i 

(IS,  II 

•jn 

(V'J 

(Ml 

Trn,-,.. 

(III 

no 

iii.i 

Trnro. 
5.5 
Faint  trn 
■I'l.ii 

;ii.o 

41;. 8 

s.s 

X'.H 

1       Traie 

Traco. 

Trarc. 

."m.ii 

li  0 

.111 

nil 

L'dO 

r:;   I     8,0  I 

1.-.      Kin  I 

25."  I 

.    I    18.0 

■-'.%   ITriKP.l 

I"   I      T.fl   I 


I-.   !    I.M 


i  1  t'S.S 

"II    I  15.0 

1:1    I  Irtfl 

I 


I 


4.15 

i;i.o 

.■11.2 

:iN.ii 

an  5 

7  I 

12  5 
1 2.(1 

20.3 

.■1.1.8 


580 
4011 
45.2 


IMrcl   4    111    II.      .\ul..psy:    ,\rl.rf>w,l,.|-„sK.   my.i,-.iirli(  U,   Mr, it.,   .irill.il   Mn,i   I  ri.ii  ,|,i,l 
11    l".'anlllls,    .Mrlll..    „n.l     ll,..,l..| ;,  Ir    ,Ih..1H,'    ,lin-|vr     ll..|,lllili.s;    ,„ I.,!,!,  1  it  l^    „f 

"Illy  II   |,.».  (I..HS    ilnriillon  ' 

i',!,M    *■,."•,  "i;.'''i'l"al  '•iiib..liw.     ,\,iin|wv  .•l.-,.-ir.  :    riroialhv  ani'tl,-  .■mln.anliiN. 

.      I"   \.);i'iaiiyn  ,ii,l„,  aniitis   l,.ri   .nirirh.  ;   .ardl.ic  (illalalliMi  ami  In  p.fti  ..pliy. 
■  linailc  II11.-MVC'  .iiiiHi  sill, n  iif  vi..,  .1:1  ■'  '     • 

.\ut..p»y  :    .\lii,l,.|-ali.  Kfailc  of  chn.i.ii   .lilliiv,.  i,,.|,1,iIik 

M.  ■!  ciipi, ,11111. inia  Ivii  ilavB  laliT  ;  n.i  (.piiati..n       \iit..i...\       \V. 

p"h.v~li,-  ki.lll.y.s.  '    •    ■ 

"'■'I   -I    "•   III.  Ill  i<. ma.     .\iil..p-.y:    .Si'ViT..  aliiyli.i.l  11.  plii  ii  U, 


il.  V.' ,1  d..iil.l. 


''■■'''    "    'I    'II     .\iil"P-v:     Siii.iU   i;iiii,iil,ir  ki.lii.ys.   ..iip..riMip..-..,|;i..r,.  ii,.pliriiis. 

1    1111     .l.,iil,l,.  ni'phn.tnmy  :  ,ll,..l  i„   iw.niy  (-..lu-  l„.,ii-;   lJ,li„.vs  liii.  ,1   uiMi 

■  a!.. III.  hi'lii;;  111, .10  ililiMvallid  pii,^  ^al^. 


.f  li.  ai  I    fiiihir 


l'l-ii.<lat,'c.|,,iiiy    -J    1    111;  ,ii,,i   iu.lv,.   h.Mirs  all.T  ra 

an,'»tli..sia 
.\,ll,)psv.     S„m,.   iiiy„.aniill..   ;iii.|   arl.ri.,^,  I.t,,,:..   sli,;l,i    ..liniiii,     n.p|„.|ij.,    .|i,:|i, 

(lil:.Mil..n  ,,1  p,  lv,>;  iliMi,!..  M-iii,.r,,il  anas  ,,f  a.  in..  |..u.|..n..plii  in- 

W.  ,,t   Int. I  .  ,.iiia  1    IS   111  :,ii,i  ,ii,  ,1   I    t;i   1,1 

.\,it..p-y  :    S..ti,..  ,lil:il;i,|„„  ,.f  ,„.|v.s,  wlli.li   vv.i-..  1,11.  ,1   with  p.i- :   n,.i,k.-.l  .•i.i.l.'-  ..f 
"•■'-'■'•Kli- lliniH,   kl.ltlrys  b..lli«    ■„    „,,,„ii,|   ^ur;   ...„i..'.|i,T„M,   pvl'.n.pl 

.\iit..i.-y  .'ill..'.!:     |.-atly  ,l,.t-i'ii..faii,,„  ,,f  vi-y.  I'n.  im|,i,|ii,_  |,i.ii,.», 
IM..1    in   iir.  tiii.i   4    11    II. 

■^"Jmr,'!,',,,!'"',"""  r""'''  ;'^'. '"■"■'.''■  inti  i-Utlal  n.-phiiii.  ;  ..„i...s  alii,.,.|  ,|,  .,,,.>..!  : 
^iip.'i  imp.. .^.,,1  ..Kilt,,  ri.plirlti.*   iVi  ■ 

«hnu-",',",-i'"H"'  ,"""""""■    '   -"   ;>      .Mi'iil-v:    My,..a,-,|it l<.  p.,ri.ai i.  ;  l.iiln.v. 

:'z,!:";^;z::rZur{u: """ ""  '"""'"^  ""^ ■""'"•'"^ """  ■> ■^■" 

"",'.''   '    ",'    "  ,1  ■^'",;'l'">    ;•*'■"■    'liri.nl.'  an.l  a,-  •.■  iiiili.il  ,i,i,!  ;i,.it|,.   niv,.,anlit  i- 
"I ''  lai.lla.    illlalalli.n.  :i.  ,il,.  unil  ni,-.|.  rat.    ,lir..iii,    liitT.i..,   n.pliriti- 

.V.  j.lii...  I..111V   iiiiil   rluhi   kl.In.y   f,,i:n,l  aln...^l   .ntlnlv  .l.,«.i.,vr,t     ,|i.  ,|   f,,,„    ,Pn< 

'"^uHiri.r;:;;!-:,;;;:";:,,^;:;.,  -^^iZ'^J^lir'""  ■" -"- "-■'""  --'■' 

M.  ,1  I.  1,  ilayv  aft.T  lii-t   I.  -t.  In  iir.  iiil.i 

.Mil^ipsv  .-li.vs      (11,1  ,lii„iil,'  |.y..ri.-|.l,r,isls  „f  l..fi  kl.ln.  v  :   ri;;l,i  ki.ln.'V  l,vp..rti.,|.lii..,l 

l,n     vlnmint'  rl,r..nl..  ,1  fT„.,.  n.plirltl.^  nn,l  a  tnark.,1  ,li(r,i...  a.-iit..' pv,.l.m,,pli',  His 

'.,t'.,l"',',.'.',nyi.'"'i"''T    '   i    '"';.  «i';k-   aft.r   „p..ralh,n    n,y..,  ai  ,|il  Is   l.,.,an,..  .y^^vH 
<.it.-,l.  iininia  di'vihip,  il.  ,,i,.i|nL'  In  il.ath, 

i-r,  "i,',7  •.'.''„!  ■     '"(■"""••  '■1'^'"  '■I''":-''-  ■■   III'  l<l''"">-  "li'i^i'il  •  liiiini.'  ,I1IT ,i,.i.hillN 

.11         I        ,  "'"'."'■   '■'r  "'l-*'!""^!"  ;   "llil    will    fill-   111 v~:    1...  am, -ll,,;,l...l 

urfnil.i  (l,.v,.l.ipi.,|  iind  (ll,.||  »„ni,.  ,|,iv»  |,ii,.r  

'''I'a'ili'    •'■■♦'■'"•     -^"''i'   iiK'li'rlllK  and   |.y,-lllls;   .  hr..iii,-  .iliTii.,,   n,  pluMis  ..f   ..  v.i. 

"'Kl.lm.vJ'l'i','  i'";'  '"""«lni»  I"-"",'-""i-"iniv.  friim  ,•,  rclirnl  lii.ni.,rrliaKe      .\((lo|w>-  : 
III    1  -  .irt.Tl,iK,-|..r„i:,.  r.,riii  .,f  n.  I'liritls  '    '' 

hr,  .■t";,',ii',',       )'"   '""'"■,   '''"■""''■  iii.vnrardltls.   arl.Tlas.-lorosls  :  ,-lir„ii v«llll.. 

riMi.  iir.ipln    „r    p,..sini,..    r.  ir..v,..|,  al    ai.„-,.ss ;    kl,ln,.v»    kIi.iwwI    K„nii.    rlimnlr 

...niih^ir:!;.''.:,';,':.,,:.!'''  """'"■''  •'"""■"■"  ■"•" ■  "»■  """•'  '«■'■"••■  ■•'  <■"'"»••« 


^A 


54 

till'  Ulhi'lt-lllnii.--  I'lirM-  Wii-  |i|.'i);ii)l\   Mii:i!l  illld  ('( ill  lillril.  -d  tli;it   ,lie  ii'lll.-;  ill - 
iiiLT  lu'iiltliy  ]ii'itiiiii  |iinl.:ili!y  iiml  1  Avriil  i()iii|Hns;iliir\  li\  |i('rlri;i'!'v. 

ci)Mi'.\i;i-ON    1)1'   I'll  III  \i.i:iN    i;\(  iiLiiov    with    ai.-toi'sy    iimiiniis 

An  o)i|i(iituiiit\  \\;i>  ;iil'i)riliil  ill  t«fnty-iiii(>  r;i.-o-  (.-i'(>  Talilc  ]'i)  ..f 
(•i.in|i;iriiii:  till'  jililliaifiii  fxcrolidii  witli  the  ]i;itli(il(ii.'ir;il  cnnilitioii  nt  ilic 
kidiicvs  lit  luit'ii'-y. 

Ill  tlic  cii-i'-  in  v.liirl;  tlh  |>lit  liii  k'ili  I'Mivli.in  \v,i-  liiiiilcnih'lv  .liirciwnl 
the  kidiH'vs  showcil  modiMiitc  iinthol(i;_:i<  al  <  hiiintri'-.  In  thu-c  casi-  in 
whirh  nil  ]ihtliahMn  ua,-  dM-n.'ttd.  ni-  mdv  a  -iiial!  aiiiniiiit.  cxte-  ,-ive  and 
sovi'i-r  renal  di-triut;i>ii  wa»  iiivarialdy  tniiiid. 

li;  niii-  la^ait  ca-r  i  \,i.  I  I,  'I'aM.-  1 '.' l  -hnw  m--  an  cxtietioii  nf  1. ■',..-)  y^-y 
(Ciit.  fur  twii  liiMir~.  «hirli  is  a  il-linili'  lii;l  nindci-ati'  rcdiictidii.  onl\'  a 
jias>;ive  L'i)ns'('>tioii  \ia-  tound.  'I'liat  thi.-  iimditinn  an  ii!(i'i-|'on>  with 
fiinctinii  nthi'r  rliniral  i  a-i<  -c  m  tn  Kinliriii. 

Ill  one  ca.-c  ilmiMi'  polycystic  kidneys  ucic  ciinninlcrctl.  a'll!oiii:h  liic 
Iilitlialcin  cxcictioii  wa-  nciinal.  The  ]iaticiit  cxhiliitcd  im  syiiiptdiii- 
fi'iiii  this  (I'lidition  dininir  life  d'-alli  hciiiLr  due  In  |iiieiiiiionia.  'I'lic  fai't 
that  polycyslie  kidiii'\-  iiiav  he  pre-eiit  i'oi  a  ^rcat  many  vcirs  wii'eiiit 
syiiijitniiis  ainl  al-n  thai  tiny  are  ii~ua!ly  iiiic'\]ioc(c(lly  di-ici\ered  at 
aiitnpsy  ill  patients  duni.'  ruiin  n\\,:-i-  lendition?  is  ijooil  proid'  of  their 
funcliiinal  enieioncy. 

1  o\i  i.rsioNs 

1.  'The  ah-orptiiai  >■(  plieiiiil-nlph.diieplilhah  in  I'oihiw  ill:;  injection  iiit" 
thi'  liinihar  inii<c!es  i~  hetter  than  the  ah-orpiicii  fniiii  the  <;!nteal  injec- 
tion, w  hilf  tlie  latter  is  siipeiioi  to  siiln  n  I  ant  on-  inji  ction 

y.   Adiiiinist ration   into  tlie  lunihiir  nni-cle-   i-  the   meihoi]  of  choi(  c. 

.1.  Exiierinientiilly  those  diureties  that  sliimilalc  ihe  renal  lells  (o 
im  rea-ed  ailivilv  caii-e  some  iiicica-cd  secretion  of  pheiiolviilphone- 
plithaleiii.  while  iho-o  that  ait  meclianically  produce  no  increased 
.secrrtioii.     ( 'liiiienllv  diiiielh-  do  n.i|   indiience  the  piithaleiii  oiilonl. 

I.  l/\]ieriiiicnlal  i\idiiice  -ci  m-  (o  imlieale  thai  pheiio'-idphone 
phlhaleiii  i-  exiretid  mii-tl\  hy  llie  liiliidc-  hut  piohahly  aUii  to  a  ~'iL'ht 
extent  hy  the  elonieiiili. 

o.  The  renal  (ells  di-play  a  -Irikins  siieidfieity  in  tie'  rxcietieii  of 
plienojsulplioiicplitliiilein. 

*!.  'I'he  ]ihenol-iilphnneplitlm!eii)  lis  ii^ed  hv  iw  has  main  '.dvaiitages 
liver  all  other  futictioi'iil  te-(s  so  far  piopo-ed. 

",'.  It  is  better  iiilapied  for  nse  n?  a  functional  test  than  aii\  other 
diuv  picvioiisly  employed  for  the  same  purpos(>,  on  ac  iiiint  of  its  cnrlv 
appenratice  in  the  nriii''  and  the  rapiilih-  and  completcne-s  of  its  (dimi- 
nati'n  hv  the  kidnev  and  the  reliance  to  he  plaeed  on  it-;  (Indinjis. 


> 


65 

'''■   'I'll''    111,  liind    (if   i|iiaiilil;ili\('    i-l  iiiiiil  ion    nf    iliii    ■imniinl    nf   driiLr 

C.Xvlvtcd    is   .-|||||ilc   illlll   ('\(r.  (lin-ly   ,■!.  l  lll-;ll|.. 

II.  It  i-  nr  iiriipoiisr  value  fi.in:  .-i  .!i:i,;,'iio~tii'  and  piu-nostio  stand- 
I'liint  III  iiciilirilis  ii;a<inmli  a.>  it  revmi  ilir  ,h.:m>  of  functional  doran.irr- 
iiiont  in  ni'ii],!ili,^  ulicllur  of  ili,.  aeiitr  or  ihroiiii-  \arictv. 

l'»,  |]i  tliu  (ardiniriial  cases  ?o  far  -studied  the  tc-t  has  proved  of  valuo 
in  dclcrniiniiij;  to  wliat  dr!;tvo  rrnal  insnilicicncv  wa-;  ivs|),,nsih!o  for  |ho 
clinical  pictiir.'  jirc-i^nlcd. 

II.  'i'hp  test  liii"  proveil  of  vahic  not  unlv  in  diaLMiosiiii:  nrcmia  from 
i-onditions  siinnlaliiMr  il.  hnt  has  also  sue,  cs-i'iiHv  indicat.d  thai  nreniin 
uas  inipciidinL'  wh.m  u,,  diniral  c\id.  ncc  n{  i|.  e\i-|,.ncc  a(  tli"  time  was 
pri'sctit. 

r.'.  'I  he  test  ha-  pi-nvcd  nf  LMvat  valin'  in  M'vcalinL'  the  tiaie  renal 
comlilinii  in  ca-i-^  ul'  ininarv  oh-trncl  i..n.  It  is  here  of  more  value  tlinn 
the  nrinarv  (,utput.  total  -ciids  in.a  or  total  iiitro-,  n,  and  ciiahle^  the 
Miri:eon  to  M'lect  a  time  for  opciatinn  wjan  the  kidnevs  arc  in  tlieir  most 
favorahlc  fnrictiona!  condition.  The  inipiovMcent  in  the  lenal  ...iidition 
m  rasos  of  nrinarv  ohstnidion  fol'owinLT  the  in-tii  ut  ion  of  prelmnnarv 
treatment  is  strikinLrlv  indicitcd  hv  this  tr^st. 

1".  In  nnilatcial  and  hilaleral  kidney  di.soases  the  absolute  amount 
of  w.uk  done  hv  each  kidi:ev  as  well  as  the  relative  proportion  can  he 
ilcterinini'd   when   the  mines  aie  ohtained  s,.parately. 

Il    \<   «itli   (lie  -iral.'M    picaMOc  lliat    we  tliaiik   lti.   !l     II.   ^,,n,|^-  f,„    |,i,  ,..|rly 

•""'  ■"iilii I  iiiicic^t  ill  tlii-  nnvU  aid  fnr  tlie  L'-iicoia-  -iipplv  cf  clnnral  ,i!  ,;,.. 

ri.il  ivf,a,.,l  (,,  „.  l,v  liini:  Dr.  Ilaikcr.  Dr.  TIk..^,-,  .,,i.1  (he  ..tli'or  incniUa  <  .if  (lu- 
stair  (,f  III,,  me.lical  clinic  fur  tic  o|.i.(ntiiiii(v  ..f  Mii.hiiiL'  llic  car.liac  aii.l  nciiji. 
ritic  rasps:  Dr.  G.  }..  Iliinncr  and  Or.  K.  K.  Ciillcn  fnr  (lie  privilc-o  ,,f  stn.lvin" 
many  siirfiioal  nITccdons  nf  tlio  kidney-.  Dr.  V.  W.  lleMnn.oi  f.,r  liis  ^;,l^■al.le 
a--i-laiice  in  carryin;.'  on  ( Ic-  work;  an. I  Hi  Diinniicr  cf  il,e  tlnii  el"  ll>ii-eii  ami 
Weseull    fnr   (he    <a l;ili..neplit !ia lein    eiai.hnel    Ih.niiL'heiit    ti,;.,    inve-ii„:'iiicn. 


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